Name *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Day Phone *

(###)

###

####

Evening Phone *

(###)

###

####

Do you wear glasses? *

Never

Full-Time

Part-Time

Distance Only

Near Work Only

What type of glasses do your own? *

Single Vision

Progressive

Bifocals

Trifocals

Safety Glasses

Sports Glasses

Backup Glasses

Readers

Other

None

Do you use a computer? *

Yes

No

If you wear eyeglasses, are there certain times when you would rather not?

Yes

No

If you wear eyeglasses, does your spare pair have your correct prescription?

Yes

No

Do your sunglasses have UV (ultra-violet) protection?

Yes

No

Are your sunglasses your current prescription?

Yes

No

Do you currently wear contact lenses? *

Yes

No

Have you ever tried to wear contact lenses? *

Yes

No

Are you interested in changing or enhancing your eye color? *

Yes

No

If you currently wear contact lenses, do your backup eyeglasses have your correct prescription?

Yes

No

Are you having any problems with your current contacts? *

Yes

No

Would you like to be evaluated for refractive laser surgery? *

Yes

No

Date of last eye exam

MM

DD

YYYY