1. Do you have trouble seeing far- away or up - close?  


 
 
2. What is your age?  

 
 
3. Do you currently use any of the following corrective lenses?  

 
 
4. Do you have Astigmatism?  


 
 
5. Are you pregnant or nursing?  

 
 
6. How interested are you in being able to play sports without spectacles or contacts?  

 
 
7. Yes, I would like to schedule a FREE Exam or Eye Examination. The best time to call me is  


 
 
   
Please provide us with the following contact information so that our executive can get in touch with you at your convenient time mentioned
   
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