First Name Last Name Date of Birth Email Address Contact Number Do you have any of the following eye conditions? No Keratoconus Corneal Dystrophies Allergic/Infectious conjunctivitis Corneal infections Previous eye surgery or trauma Eye lid infections Dry Eyes Other… Enter other… Do you wear correction for: Myopia (short sightedness) Hyperomia (Long sightedness) Astigmatism I wear correction lenses but I am unsure what they are for What type of correction do you wear to correct your eyesight? Spectacles Soft contact lenses Rigid contact lenses None Please complete this simple math question to prove you are not a robot 7 + 2 = Solve this simple math problem and enter the result. E.g. for 1+3, enter 4. Leave this field blank
