Are you a Candidate?

We recognize that your eyes are very important to you. We would like to know how you use your eyes on a daily basis. Along with your eye exam, this info will assist us in recommending the best options for your eyes and your personal lifestyle vision.

Personal

Email *

Date of birth

Occupation


 Active Retired Student

Vision

Do you need corrective lenses to improve your distance vision?  Yes No

Do you use reading glasses?  Yes No

Do you wear contacts?  Yes No

If so, please select the type of contacts you wear:
 Soft/disposable Hard/RGP Toric Scleral Cosmetic Bifocal

How long have you been wearing contacts?

When was the last day contacts touched your eyes?

Do you wear them overnight?  Yes No

Has your prescription been stable over the last two years?  Yes No

Please check any other reasons for problems with glasses or contacts:
 Poor comfort Dependence Occupational limitations Poor cosmetic appearance Restricts my physical activity Safety/Security Nuisance

Do you have an eye doctor you visit on a regular basis?  Yes No

If yes, please list name and locations:

When was your last eye exam?

Do you have copies of your last prescriptions?  Yes No

How did you hear about us? *
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