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* First Name: Your Name is required.

* Last Name: Last Name is required.

* Phone: Phone Number is required.Please enter a valid phone number.

* Email: Email Address is required.Please enter a valid Email Address.

* Confirm Email: Your Email Address is required.Please type carefully - the email addresses don't match.

Preferred Contact Method: Select One Telephone Email

Please tell us which day is the most convenient for you.

Preferred Day of Week: Select One Monday Tuesday Wednesday Thursday Friday Saturday

Preferred Time of Day: Select One Morning Mid-day Afternoon

If you currently wear contact lenses, your contacts must be out for one week prior to the initial consultation.

Do you know your prescription? Select One Yes No

Has it changed since last year? Yes   No   Don't Know

Do you wear monovision contacts? Yes   No

How often do you wear contacts? Select One Full-Time Part-Time Rarely Never

How often do you wear glasses? Select One Full-Time Part-Time Never

Date contacts were last worn?

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