Name *

First Name

Last Name

Birthday *

MM

DD

YYYY

Phone *

(###)

###

####

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Please check any medical condition that applies to you

Glaucoma

Lazy Eye

Blindness

Retinal Detachment

Asthma

Diabetes

Heart Issues

Thyroid

High Blood Pressure

Macular Degeneration

No Health Conditions

Please check any that apply to your family

Glaucoma

Lazy Eye

Blindness

Retinal Detachment

Asthma

Diabetes

Heart Issues

Thyroid

High Blood Pressure

Macular Degeneration

No Health Conditions

Do you currently wear contacts? *

YES

NO

Have you had any type of eye surgery? *

YES

NO

Have you experienced and type of eye injury? *

YES

NO

Do you experience ocular dryness or irritation? *

YES

NO