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Help us help you

This form is vital to assist us to determine the different optical needs in your daily lifestyle.

Which of the following eye symptoms do you experience on a daily basis?*
HeadachesGlare/Light sensitivityDouble visionSore/Tired eyesDry/Watery eyesBlurred visionBurning/Itching/Red eyes

What eye wear are you currently wearing?*
No Visual aidsSingle vision for distanceSingle vision for readingBifocal lensesMultifocal/Progressive lensesOffice ComputerSports prescriptionPrescription sunglassesEye lubricantsContact lensesSafety prescription eye wear

Please tick any of the below that apply to you:*
Have trouble seeing at nightEyes are sensitive to reflection off water surfacesStruggle to see far/watching TV/reading traffic signsMy eyes are sensitive to lightImpact chemical environmentI struggle to read near/reading on my cell phone

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