Self-Evaluation

1

Select your age group* This field is required

Under 18

19-39

40-59

60+

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2

What do you usually wear?* This field is required

Radio Glasses

Radio Contacts

Radio Reading Glasses

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3

Without my glasses and contacts* This field is required

Radio I have trouble reading and seeing things up close

Radio I have trouble driving and seeing things that are far away

Radio I've been told that I have astigmatism

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4

Do you have any of the following?* This field is required

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5

Can we get your name?* This field is required

First Name

Last Name

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6

What is your phone number?* This field is required

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7

What is your email?* This field is required

[email protected]

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8

The best way to contact you is?

Phone

Email

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9

I consent to receiving email marketing communications.* This field is required

YESNO

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10

Status

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11

Referrer

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12

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PPC Self-Eval