First Name (required) Last Name (required) Your Email (required) Phone Number (required) In the past 3 months, have you been pregnant/nursing/breastfeeding?* YesNo What type of refractive error do you have?* Nearsightedness (myopia) -- you have trouble seeing distanceFarsightedness (hyperopia) -- you have trouble seeing up closeReading (presbyopia) -- you have trouble seeing intermediateI don't know Do you have astigmatism?* YesNoI don't know
When was your last noticed vision change (date)?* Do you have any of the following conditions? Keratoconus or other corneal thinning disorderCorneal scarringGlaucomaCataractsOcular herpes diagnosed in past yearDiabetesAutoimmune disease (for example, AIDS, lupus, rheumatoid arthritis, multiple sclerosis, or myasthenia gravis)Immunocompromised for any reasonCollagen vascular disease My preferred method(s) of contact is: EmailPhoneSnail Mail
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2500 E. Beltline Ave. SE Grand Rapids, MI 49546
firstname.lastname@example.org Call: 616.365.5775 Fax: 616.365.5778 Toll Free: 800.806.3554
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