What is your age? *

Under 18

18 - 44

45 - 66

66 & Up

What is your current vision (without) glasses? *

I can't see far away

I can't see up close

I can't see anything

What do you wear most? (90% of the time) *

glasses

contacts

glasses & contacts

nothing

Would you consider yourself to be generally healthy? *

Yes

No

Do you require reading glasses? *

Yes

No

Have you ever had an eye injury or eye surgery in the past? *

Yes

No

(Such as previously having Laser Vision Correction)

What is your biggest frustration with glasses or contacts? (Optional)

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Full Name *

Email *

Phone *

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