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| E-mail Address: * |
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| City: |
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| Telephone: |
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| Mobile Phone: |
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| Mobile Carrier: |
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| Other Carrier: |
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| Demographic Information: |
| Gender: |
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| Date of Birth: |
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| Income: |
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| Vision Information: |
| Do you wear contacts? |
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| Do you wear prescription glasses? |
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| Do you wear prescription sunglasses? |
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| Do your eyes get dry? |
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| Are you interested in vision correction? |
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| Do you go to a privately owned local optometrist/vision care center? |
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| Do you go to a national vision care chain? |
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