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FAQ
Computer use per day:
*
Choose one
< 2 hours
2 - 6 hours
> 6 hours
Are you interested in wearing contact lenses?
*
Choose one
Yes, for everyday use
Yes, for sports/special occasions
No
I am currently a contact lens wearer
Email:
*
Hobbies / Activities:
*
Baseball
Basketball
Biking
Football
Golf
Racquetball
Skiing
Soccer
Tennis
Volleyball
Hiking
Fishing
Motorcycle
Running
Shooting/Hunting
Swimming
Yard work
Reading
Travel
Crafting
Music
Painting
Woodworking
Video Gaming
None of aforementioned
Name:
*
Thank you for completing your paperwork! Be sure to bring your insurance card and picture ID for your appointment.
8. What is important to you regarding your eyeglasses?
*
Comfort
Optimized Vision
Glare Reduction
Latest lens technology
Thin Lenses
Back up pair
Updating your look
Eyewear Wardrobe (work, evening, suns)
Melanoma Prevention
Today's Date:
*
Date of Birth:
*
Occupation:
How many pairs of eyeglasses do you currently own?
*
Do you use a tablet or smartphone?
*
Choose one
Yes
No
6. Have you had any issues with your vision while driving?
Lifestyle Questionnaire
7. Please list any trouble with past eyeglasses:
821 North Main St. Ext
Wallingford, CT 06492
Phone: 203.265.5152
Fax: 203.265.1562
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