Your age group Please Select Your Age Group Under 18 19-39 40-59 60+

Have you noticed any deterioration of your vision in the past 5 years? Yes No

Were your first glasses more for reading or distance? Distance Reading

Without my glasses and contacts Select Option I have trouble reading and seeing things up close I have trouble driving and seeing things that are far away I have been told that I have astigmatism

What do you usually wear?
Select Option Glasses Contacts Reading glasses

Describe your vision(select all that apply)
Blurry or cloudy vision
Not as colorful or vibrant as it used to be
Halos around lights and/or over-sensitivity to light
Poor night vision
Double or multiple images in one eye
None of the above

Best way to contact you?
Phone Email

What is your phone number?

What is your email?

I consent to receiving email marketing communications.
Yes No