1. Name: *

2. Email: *

3. Phone Number: *

4. How old are you? * 18 - 3536 - 5556 - 6061+

5. Do you wear? * SpectaclesContact LensesReading SpectaclesVarifocal / multifocal Spectacles

6. Without corrective lenses do you? * Have trouble reading and seeing up close (far-sighted)Have trouble driving and seeing things far away (near-sighted)See fuzzy images when reading on a board (astigmatism)Short-sightedness and astigmatismFar-sightedness and astigmatismNone of the above

7. Do you know your prescription? * -0.25 to -2.00 (Shortsightedness)-2.25 to -5.00 (Shortsightedness)-5.25 to -10.00 (Shortsightedness)-10.25 or more (Shortsightedness)+0.25 to +3.00 (Farsightedness)+3.25 to +6 (Farsightedness)+6 or more

8. Have you ever been told that you have dry eyes? * YesNoI don't know

9. If you are a woman - are you currently: * PregnantNursingNone of the above

10. Do you have any of the following eye conditions (please select all that apply) * AstigmatismKeratoconusGlaucomaCataractsRetinal DiseaseCorneal ScarringMacular DegenerationNone of the above

11. Do you have any active or uncontrolled auto-immune disorder? * YesNoI don't know

12. Have you had eye surgery before? If yes, please describe the details in the box below

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