• Format: +1 (000) 000-0000.

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  • What is your age group?
  • Without my glasses and contacts...(Check All That Apply)*
  • What do you usually wear? (Check All That Apply)*
  • Do you have any of the following? (Check All That Apply)*
  • Rate this statement on a scale of 1 to 5 with 1 being the lowest: I would like to see well at a distance without relying on glasses and contact lenses.*

  • Rate this statement on a scale of 1 to 5 with 1 being the lowest.

  • Rate this statement on a scale of 1 to 5 with 1 being the lowest: I would like to see well up close without relying on glasses and contact lenses*

  • Rate this statement on a scale of 1 to 5 with 1 being the lowest.

  • Would your lifestyle improve if you were to become less dependent on glasses and contact lenses?*

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