ESI.jpg

This survey has been provided by and will be submitted to Glaukos.´╗┐

*Please complete and submit the entire survey.*

* 1. First and Last Name
0/50
* 2. Email Address
0/50
* 3. Mailing Address
0/50
* 4. City
0/50
* 5. Zip Code
0/50
* 6. State
0/50
* 7. Phone
0/50
* 8. Organization (Practice / Clinic)
0/50
* 9. Job Title
0/50
* 10. What is your OE Tracker Number?
0/50
* 11. Approximately how many new cases of keratoconus or corneal ectasia are diagnosed in your practice each year?
* 12. Do you recommend FDA-approved corneal cross-linking for your patients with progressive keratoconus?
* 13. If/when you need to refer a patient for cross-linking where do you send them?
0/50
* 14. What diagnostic equipment do you have available in office and/or use to diagnose keratoconus? (Select All That Apply)
* 15. Are you aware that there is only one FDA-Approved cross-linking device and drug combination in the U.S.?
* 16. Compared to this time last year, how much patient volume are you currently seeing?
* 17. Compared to this time last year, how much have your referrals to surgeons changed?
* 18. In your practice, do you accept vision insurance, medical insurance or both?
0/50
* 19. Would you like to receive more information on cross-linking or patient education materials via email?
* 20. What is your state license number?
0/50