Below are the Patient Questionnaire and Symptoms checklist. Patient Questionnaire Symptoms Checklist Please fill out the following form, and we will contact you as soon as possible. (Please fill out all fields.) Name: Address: City: State: State AL AK AZ AR CA CO CT DE FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY Zip: Phone: Email: Tell us about your current eye doctor: Eye doctor: City: State: State AL AK AZ AR CA CO CT DE FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY Contact Information Email: Gregory S. Moore, O.D. Mailing Address: 50 Riverwalk Mall South Charleston, WV 25303 -VIEW MAP- Phone: 304.768.7902 Fax: 304.768.7932   1-888-EYES 4 YOU Gregory S. Moore, O.D. 50 Riverwalk Mall South Charleston, WV 25303 Copyright ©2001 West Virginia Laser Eye Center Site maintenance by Dream Catcher. -Acknowledgments-