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What types of eyewear do you use now? (Check all that apply)
Contact LensesPrescription EyeglassesDime Store Reading GlassesNone of the Above

Which statement best describes your need for glasses or contact lenses?
To see objects and text up closeTo see things far awayTo see clearly at all distances

Is your current prescription stronger than -7? (-8, -9, etc.)
YesNoNot Sure

Please fill out the information below so we can email you your results!

First Name*

Last Name*

Email Address*

Phone Number

Birthday* (knowing your age helps us provide more accurate recommendations)
Month123456789101112 Day12345678910111213141516171819202122232425262728293031 Year19201921192219231924192519261927192819291930193119321933193419351936193719381939194019411942194319441945194619471948194919501951195219531954195519561957195819591960196119621963196419651966196719681969197019711972197319741975197619771978197919801981198219831984198519861987198819891990199119921993199419951996199719981999200020012002200320042005200620072008200920102011201220132014201520162017201820192020

How may we help you learn more? (Check all that apply)

I'd like to schedule a free consultation

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