{"id":3168,"date":"2018-10-15T15:20:00","date_gmt":"2018-10-15T15:20:00","guid":{"rendered":"https:\/\/courtsoptical.com\/guyana\/?page_id=3168"},"modified":"2018-10-15T15:20:17","modified_gmt":"2018-10-15T15:20:17","slug":"patient-form","status":"publish","type":"page","link":"https:\/\/courtsoptical.com\/guyana\/patient-form\/","title":{"rendered":"Patient Form"},"content":{"rendered":"\n<div class=\"wpcf7 no-js\" id=\"wpcf7-f3169-o1\" lang=\"en-US\" dir=\"ltr\" data-wpcf7-id=\"3169\">\n<div class=\"screen-reader-response\"><p role=\"status\" aria-live=\"polite\" aria-atomic=\"true\"><\/p> <ul><\/ul><\/div>\n<form action=\"\/guyana\/wp-json\/wp\/v2\/pages\/3168#wpcf7-f3169-o1\" method=\"post\" class=\"wpcf7-form init wpcf7-acceptance-as-validation\" aria-label=\"Contact form\" novalidate=\"novalidate\" data-status=\"init\">\n<fieldset class=\"hidden-fields-container\"><input type=\"hidden\" name=\"_wpcf7\" value=\"3169\" \/><input type=\"hidden\" name=\"_wpcf7_version\" value=\"6.1.5\" \/><input type=\"hidden\" name=\"_wpcf7_locale\" value=\"en_US\" \/><input type=\"hidden\" name=\"_wpcf7_unit_tag\" value=\"wpcf7-f3169-o1\" \/><input type=\"hidden\" name=\"_wpcf7_container_post\" value=\"0\" \/><input type=\"hidden\" name=\"_wpcf7_posted_data_hash\" value=\"\" \/><input type=\"hidden\" name=\"_wpcf7_recaptcha_response\" value=\"\" \/>\n<\/fieldset>\n<div id=\"responsive-form\" class=\"clearfix\">\n\t<p class=\"text-center\">* These fields are Mandatory\n\t<\/p>\n\t<div class=\"form-row clearfix\">\n\t\t<div class=\"column-half\">\n\t\t\t<p>First Name* <span class=\"wpcf7-form-control-wrap\" data-name=\"first-name\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"first-name\" \/><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"column-half\">\n\t\t\t<p>Last Name* <span class=\"wpcf7-form-control-wrap\" data-name=\"last-name\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"last-name\" \/><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n\t<div class=\"form-row clearfix\">\n\t\t<div class=\"column-half\">\n\t\t\t<p>Email:* <span class=\"wpcf7-form-control-wrap\" data-name=\"your-email\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-email wpcf7-validates-as-required wpcf7-text wpcf7-validates-as-email\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"email\" name=\"your-email\" \/><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"column-half\">\n\t\t\t<p>Confirm email:* <span class=\"wpcf7-form-control-wrap\" data-name=\"your-email-confirm\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-email wpcf7-validates-as-required wpcf7-text wpcf7-validates-as-email\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"email\" name=\"your-email-confirm\" \/><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n\t<div class=\"form-row clearfix\">\n\t\t<div class=\"column-half\">\n\t\t\t<p>Area* <span class=\"wpcf7-form-control-wrap\" data-name=\"menu-259\"><select class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required form-control\" aria-required=\"true\" aria-invalid=\"false\" name=\"menu-259\"><option value=\"Guyana +592\">Guyana +592<\/option><option value=\"Afghanistan +93\">Afghanistan +93<\/option><option value=\"Albania +355\">Albania +355<\/option><option value=\"Algeria +213\">Algeria +213<\/option><option value=\"American Samoa +1684\">American Samoa +1684<\/option><option value=\"Andorra +376\">Andorra +376<\/option><option value=\"Angola +244\">Angola +244<\/option><option value=\"Anguilla +1264\">Anguilla +1264<\/option><option value=\"Antarctica +672\">Antarctica +672<\/option><option value=\"Antigua and Barbuda +1-268\">Antigua and Barbuda +1-268<\/option><option value=\"Argentina +54\">Argentina +54<\/option><option value=\"Armenia +374\">Armenia +374<\/option><option value=\"Aruba +297\">Aruba +297<\/option><option value=\"Australia +61\">Australia +61<\/option><option value=\"Austria +43\">Austria +43<\/option><option value=\"Azerbaijan +994\">Azerbaijan +994<\/option><option value=\"Bahamas +1242\">Bahamas +1242<\/option><option value=\"Bahrain +973\">Bahrain +973<\/option><option value=\"Bangladesh +880\">Bangladesh +880<\/option><option value=\"Barbados +1246\">Barbados +1246<\/option><option value=\"Belarus +375\">Belarus +375<\/option><option value=\"Belgium +32\">Belgium +32<\/option><option value=\"Belize +501\">Belize +501<\/option><option value=\"Benin +229\">Benin +229<\/option><option value=\"Bermuda +1441\">Bermuda +1441<\/option><option value=\"Bhutan +975\">Bhutan +975<\/option><option value=\"Bolivia +591\">Bolivia +591<\/option><option value=\"Bonaire +599\">Bonaire +599<\/option><option value=\"Bosnia and Herzegovina +387\">Bosnia and Herzegovina +387<\/option><option value=\"Botswana +267\">Botswana +267<\/option><option value=\"Brazil +55\">Brazil +55<\/option><option value=\"British Indian Ocean Territory +246\">British Indian Ocean Territory +246<\/option><option value=\"British Virgin Islands +1284\">British Virgin Islands +1284<\/option><option value=\"Brunei +673\">Brunei +673<\/option><option value=\"Bulgaria +359\">Bulgaria +359<\/option><option value=\"Burkina Faso +226\">Burkina Faso +226<\/option><option value=\"Burundi +257\">Burundi +257<\/option><option value=\"Cambodia +855\">Cambodia +855<\/option><option value=\"Cameroon +237\">Cameroon +237<\/option><option value=\"Canada +1\">Canada +1<\/option><option value=\"Cape Verde +238\">Cape Verde +238<\/option><option value=\"Cayman Islands +1345\">Cayman Islands +1345<\/option><option value=\"Central African Republic +236\">Central African Republic +236<\/option><option value=\"Chad +235\">Chad +235<\/option><option value=\"Chile +56\">Chile +56<\/option><option value=\"China +86\">China +86<\/option><option value=\"Christmas Island +61\">Christmas Island +61<\/option><option value=\"Cocos Islands +61\">Cocos Islands +61<\/option><option value=\"Colombia +57\">Colombia +57<\/option><option value=\"Comoros +269\">Comoros +269<\/option><option value=\"Cook Islands +682\">Cook Islands +682<\/option><option value=\"Costa Rica +506\">Costa Rica +506<\/option><option value=\"Croatia +385\">Croatia +385<\/option><option value=\"Cuba +53\">Cuba +53<\/option><option value=\"Curacao +599\">Curacao +599<\/option><option value=\"Cyprus +357\">Cyprus +357<\/option><option value=\"Czech Republic +420\">Czech Republic +420<\/option><option value=\"Democratic Republic of the Congo +243\">Democratic Republic of the Congo +243<\/option><option value=\"Denmark +45\">Denmark +45<\/option><option value=\"Djibouti +253\">Djibouti +253<\/option><option value=\"Dominica +1767\">Dominica +1767<\/option><option value=\"Dominican Republic +1809\">Dominican Republic +1809<\/option><option value=\"East Timor +670\">East Timor +670<\/option><option value=\"Ecuador +593\">Ecuador +593<\/option><option value=\"Egypt +20\">Egypt +20<\/option><option value=\"El Salvador +503\">El Salvador +503<\/option><option value=\"Equatorial Guinea +240\">Equatorial Guinea +240<\/option><option value=\"Eritrea +291\">Eritrea +291<\/option><option value=\"Estonia +372\">Estonia +372<\/option><option value=\"Ethiopia +251\">Ethiopia +251<\/option><option value=\"Falkland Islands +500\">Falkland Islands +500<\/option><option value=\"Faroe Islands +298\">Faroe Islands +298<\/option><option value=\"Fiji +679\">Fiji +679<\/option><option value=\"Finland +358\">Finland +358<\/option><option value=\"France +33\">France +33<\/option><option value=\"French Polynesia +689\">French Polynesia +689<\/option><option value=\"Gabon +241\">Gabon +241<\/option><option value=\"Gambia +220\">Gambia +220<\/option><option value=\"Georgia +995\">Georgia +995<\/option><option value=\"Germany +49\">Germany +49<\/option><option value=\"Ghana +233\">Ghana +233<\/option><option value=\"Gibraltar +350\">Gibraltar +350<\/option><option value=\"Greece +30\">Greece +30<\/option><option value=\"Greenland +299\">Greenland +299<\/option><option value=\"Grenada +1473\">Grenada +1473<\/option><option value=\"Guam +1671\">Guam +1671<\/option><option value=\"Guatemala +502\">Guatemala +502<\/option><option value=\"Guernsey +44-1481\">Guernsey +44-1481<\/option><option value=\"Guinea +224\">Guinea +224<\/option><option value=\"Guinea-Bissau +245\">Guinea-Bissau +245<\/option><option value=\"Haiti +509\">Haiti +509<\/option><option value=\"Honduras +504\">Honduras +504<\/option><option value=\"Hong Kong +852\">Hong Kong +852<\/option><option value=\"Hungary +36\">Hungary +36<\/option><option value=\"Iceland +354\">Iceland +354<\/option><option value=\"India +91\">India +91<\/option><option value=\"Indonesia +62\">Indonesia +62<\/option><option value=\"Iran +98\">Iran +98<\/option><option value=\"Iraq +964\">Iraq +964<\/option><option value=\"Ireland +353\">Ireland +353<\/option><option value=\"Isle of Man +44-1624\">Isle of Man +44-1624<\/option><option value=\"Israel +972\">Israel +972<\/option><option value=\"Italy +39\">Italy +39<\/option><option value=\"Ivory Coast +225\">Ivory Coast +225<\/option><option value=\"Jamaica +1876\">Jamaica +1876<\/option><option value=\"Jamaica +1658\">Jamaica +1658<\/option><option value=\"Japan +81\">Japan +81<\/option><option value=\"Jersey +44-1534\">Jersey +44-1534<\/option><option value=\"Jordan +962\">Jordan +962<\/option><option value=\"Kazakhstan +7\">Kazakhstan +7<\/option><option value=\"Kenya +254\">Kenya +254<\/option><option value=\"Kiribati +686\">Kiribati +686<\/option><option value=\"Kosovo +383\">Kosovo +383<\/option><option value=\"Kuwait +965\">Kuwait +965<\/option><option value=\"Kyrgyzstan +996\">Kyrgyzstan +996<\/option><option value=\"Laos +856\">Laos +856<\/option><option value=\"Latvia +371\">Latvia +371<\/option><option value=\"Lebanon +961\">Lebanon +961<\/option><option value=\"Lesotho +266\">Lesotho +266<\/option><option value=\"Liberia +231\">Liberia +231<\/option><option value=\"Libya +218\">Libya +218<\/option><option value=\"Liechtenstein +423\">Liechtenstein +423<\/option><option value=\"Lithuania +370\">Lithuania +370<\/option><option value=\"Luxembourg +352\">Luxembourg +352<\/option><option value=\"Macau +853\">Macau +853<\/option><option value=\"Macedonia +389\">Macedonia +389<\/option><option value=\"Madagascar +261\">Madagascar +261<\/option><option value=\"Malawi +265\">Malawi +265<\/option><option value=\"Malaysia +60\">Malaysia +60<\/option><option value=\"Maldives +960\">Maldives +960<\/option><option value=\"Mali +223\">Mali +223<\/option><option value=\"Malta +356\">Malta +356<\/option><option value=\"Marshall Islands +692\">Marshall Islands +692<\/option><option value=\"Mauritania +222\">Mauritania +222<\/option><option value=\"Mauritius +230\">Mauritius +230<\/option><option value=\"Mayotte +262\">Mayotte +262<\/option><option value=\"Mexico +52\">Mexico +52<\/option><option value=\"Micronesia +691\">Micronesia +691<\/option><option value=\"Moldova +373\">Moldova +373<\/option><option value=\"Monaco +377\">Monaco +377<\/option><option value=\"Mongolia +976\">Mongolia +976<\/option><option value=\"Montenegro +382\">Montenegro +382<\/option><option value=\"Montserrat +1664\">Montserrat +1664<\/option><option value=\"Morocco +212\">Morocco +212<\/option><option value=\"Mozambique +258\">Mozambique +258<\/option><option value=\"Myanmar +95\">Myanmar +95<\/option><option value=\"Namibia +264\">Namibia +264<\/option><option value=\"Nauru +674\">Nauru +674<\/option><option value=\"Nepal +977\">Nepal +977<\/option><option value=\"Netherlands +31\">Netherlands +31<\/option><option value=\"Netherlands Antilles +599\">Netherlands Antilles +599<\/option><option value=\"New Caledonia +687\">New Caledonia +687<\/option><option value=\"New Zealand +64\">New Zealand +64<\/option><option value=\"Nicaragua +505\">Nicaragua +505<\/option><option value=\"Niger +227\">Niger +227<\/option><option value=\"Nigeria +234\">Nigeria +234<\/option><option value=\"Niue +683\">Niue +683<\/option><option value=\"North Korea +850\">North Korea +850<\/option><option value=\"Northern Mariana Islands +1670\">Northern Mariana Islands +1670<\/option><option value=\"Norway +47\">Norway +47<\/option><option value=\"Oman +968\">Oman +968<\/option><option value=\"Pakistan +92\">Pakistan +92<\/option><option value=\"Palau +680\">Palau +680<\/option><option value=\"Palestine +970\">Palestine +970<\/option><option value=\"Panama +507\">Panama +507<\/option><option value=\"Papua New Guinea +675\">Papua New Guinea +675<\/option><option value=\"Paraguay +595\">Paraguay +595<\/option><option value=\"Peru +51\">Peru +51<\/option><option value=\"Philippines +63\">Philippines +63<\/option><option value=\"Pitcairn +64\">Pitcairn +64<\/option><option value=\"Poland +48\">Poland +48<\/option><option value=\"Portugal +351\">Portugal +351<\/option><option value=\"Puerto Rico +1787\">Puerto Rico +1787<\/option><option value=\"Qatar +974\">Qatar +974<\/option><option value=\"Republic of the Congo +242\">Republic of the Congo +242<\/option><option value=\"Reunion +262\">Reunion +262<\/option><option value=\"Romania +40\">Romania +40<\/option><option value=\"Russia +7\">Russia +7<\/option><option value=\"Rwanda +250\">Rwanda +250<\/option><option value=\"Saint Barthelemy +590\">Saint Barthelemy +590<\/option><option value=\"Saint Helena +290\">Saint Helena +290<\/option><option value=\"Saint Kitts and Nevis +1869\">Saint Kitts and Nevis +1869<\/option><option value=\"Saint Lucia +1758\">Saint Lucia +1758<\/option><option value=\"Saint Martin +590\">Saint Martin +590<\/option><option value=\"Saint Pierre and Miquelon +508\">Saint Pierre and Miquelon +508<\/option><option value=\"Saint Vincent and the Grenadines +1784\">Saint Vincent and the Grenadines +1784<\/option><option value=\"Samoa +685\">Samoa +685<\/option><option value=\"San Marino +378\">San Marino +378<\/option><option value=\"Sao Tome and Principe +239\">Sao Tome and Principe +239<\/option><option value=\"Saudi Arabia +966\">Saudi Arabia +966<\/option><option value=\"Senegal +221\">Senegal +221<\/option><option value=\"Serbia +381\">Serbia +381<\/option><option value=\"Seychelles +248\">Seychelles +248<\/option><option value=\"Sierra Leone +232\">Sierra Leone +232<\/option><option value=\"Singapore +65\">Singapore +65<\/option><option value=\"Sint Maarten +1721\">Sint Maarten +1721<\/option><option value=\"Slovakia +421\">Slovakia +421<\/option><option value=\"Slovenia +386\">Slovenia +386<\/option><option value=\"Solomon Islands +677\">Solomon Islands +677<\/option><option value=\"Somalia +252\">Somalia +252<\/option><option value=\"South Africa +27\">South Africa +27<\/option><option value=\"South Korea +82\">South Korea +82<\/option><option value=\"South Sudan +211\">South Sudan +211<\/option><option value=\"Spain +34\">Spain +34<\/option><option value=\"Sri Lanka +94\">Sri Lanka +94<\/option><option value=\"Sudan +249\">Sudan +249<\/option><option value=\"Suriname +597\">Suriname +597<\/option><option value=\"Svalbard and Jan Mayen +47\">Svalbard and Jan Mayen +47<\/option><option value=\"Swaziland +268\">Swaziland +268<\/option><option value=\"Sweden +46\">Sweden +46<\/option><option value=\"Switzerland +41\">Switzerland +41<\/option><option value=\"Syria +963\">Syria +963<\/option><option value=\"Taiwan +886\">Taiwan +886<\/option><option value=\"Tajikistan +992\">Tajikistan +992<\/option><option value=\"Tanzania +255\">Tanzania +255<\/option><option value=\"Thailand +66\">Thailand +66<\/option><option value=\"Togo +228\">Togo +228<\/option><option value=\"Tokelau +690\">Tokelau +690<\/option><option value=\"Tonga +676\">Tonga +676<\/option><option value=\"Trinidad and Tobago +1868\">Trinidad and Tobago +1868<\/option><option value=\"Tunisia +216\">Tunisia +216<\/option><option value=\"Turkey +90\">Turkey +90<\/option><option value=\"Turkmenistan +993\">Turkmenistan +993<\/option><option value=\"Turks and Caicos Islands +1649\">Turks and Caicos Islands +1649<\/option><option value=\"Tuvalu +688\">Tuvalu +688<\/option><option value=\"U.S. Virgin Islands +1340\">U.S. Virgin Islands +1340<\/option><option value=\"Uganda +256\">Uganda +256<\/option><option value=\"Ukraine +380\">Ukraine +380<\/option><option value=\"United Arab Emirates +971\">United Arab Emirates +971<\/option><option value=\"United Kingdom +44\">United Kingdom +44<\/option><option value=\"United States +1\">United States +1<\/option><option value=\"Uruguay +598\">Uruguay +598<\/option><option value=\"Uzbekistan +998\">Uzbekistan +998<\/option><option value=\"Vanuatu +678\">Vanuatu +678<\/option><option value=\"Vatican +379\">Vatican +379<\/option><option value=\"Venezuela +58\">Venezuela +58<\/option><option value=\"Vietnam +84\">Vietnam +84<\/option><option value=\"Wallis and Futuna +681\">Wallis and Futuna +681<\/option><option value=\"Western Sahara +212\">Western Sahara +212<\/option><option value=\"Yemen +967\">Yemen +967<\/option><option value=\"Zambia +260\">Zambia +260<\/option><option value=\"Zimbabwe +263\">Zimbabwe +263<\/option><\/select><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"column-half\">\n\t\t\t<p>Phone* <span class=\"wpcf7-form-control-wrap\" data-name=\"your-phone\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"your-phone\" \/><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n\t<div class=\"form-row clearfix\">\n\t\t<div class=\"column-half\">\n\t\t\t<p>Occupation* <span class=\"wpcf7-form-control-wrap\" data-name=\"occ\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"occ\" \/><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"column-half\">\n\t\t\t<p>Branch*<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"Branch\"><select class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" name=\"Branch\"><option value=\"Linden\">Linden<\/option><option value=\"Main Street\">Main Street<\/option><option value=\"New Amsterdam\">New Amsterdam<\/option><option value=\"Parika\">Parika<\/option><option value=\"Plantation Pattensen\">Plantation Pattensen<\/option><\/select><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n\t<div class=\"form-row clearfix\">\n\t\t<div class=\"column-full\">\n\t\t\t<p>How many hours a day do you use the following:\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"column-half\">\n\t\t\t<p>Computer\/Tablet <span class=\"wpcf7-form-control-wrap\" data-name=\"Computerhrs\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"Computerhrs\" \/><\/span> Smart Phone <span class=\"wpcf7-form-control-wrap\" data-name=\"Smart\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"Smart\" \/><\/span> TV <span class=\"wpcf7-form-control-wrap\" data-name=\"TV\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"TV\" \/><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"column-half\">\n\t\t\t<p>Drive <span class=\"wpcf7-form-control-wrap\" data-name=\"Drive\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"Drive\" \/><\/span> Digital Equipment <span class=\"wpcf7-form-control-wrap\" data-name=\"digitalEquip\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"digitalEquip\" \/><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n\t<div class=\"form-row clearfix\">\n\t\t<div class=\"column-full\">\n\t\t\t<p>What do you do for fun? (tick as many that applies)\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"column-half\">\n\t\t\t<p>Outdoor Leisure<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"hobbies\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first\"><input type=\"checkbox\" name=\"hobbies[]\" value=\"Fishing\" \/><span class=\"wpcf7-list-item-label\">Fishing<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"hobbies[]\" value=\"Golf\" \/><span class=\"wpcf7-list-item-label\">Golf<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"hobbies[]\" value=\"Hiking\" \/><span class=\"wpcf7-list-item-label\">Hiking<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"hobbies[]\" value=\"Hunting\" \/><span class=\"wpcf7-list-item-label\">Hunting<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"hobbies[]\" value=\"Skiing\" \/><span class=\"wpcf7-list-item-label\">Skiing<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"hobbies[]\" value=\"Motorcycle\" \/><span class=\"wpcf7-list-item-label\">Motorcycle<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"hobbies[]\" value=\"Walking\" \/><span class=\"wpcf7-list-item-label\">Walking<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"hobbies[]\" value=\"Gardening\" \/><span class=\"wpcf7-list-item-label\">Gardening<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"hobbies[]\" value=\"Yardwork\" \/><span class=\"wpcf7-list-item-label\">Yardwork<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"hobbies[]\" value=\"Birdwatching\" \/><span class=\"wpcf7-list-item-label\">Birdwatching<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"checkbox\" name=\"hobbies[]\" value=\"Travel\" \/><span class=\"wpcf7-list-item-label\">Travel<\/span><\/span><\/span><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"column-half\">\n\t\t\t<p>Sports<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"Sports\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first\"><input type=\"checkbox\" name=\"Sports[]\" value=\"Basketball\" \/><span class=\"wpcf7-list-item-label\">Basketball<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"Sports[]\" value=\"Biking\" \/><span class=\"wpcf7-list-item-label\">Biking<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"Sports[]\" value=\"Football\" \/><span class=\"wpcf7-list-item-label\">Football<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"Sports[]\" value=\"Tennis\" \/><span class=\"wpcf7-list-item-label\">Tennis<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"Sports[]\" value=\"Baseball\" \/><span class=\"wpcf7-list-item-label\">Baseball<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"Sports[]\" value=\"Racket ball\" \/><span class=\"wpcf7-list-item-label\">Racket ball<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"Sports[]\" value=\"Running\" \/><span class=\"wpcf7-list-item-label\">Running<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"Sports[]\" value=\"Soccer\" \/><span class=\"wpcf7-list-item-label\">Soccer<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"Sports[]\" value=\"Swimming\" \/><span class=\"wpcf7-list-item-label\">Swimming<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"checkbox\" name=\"Sports[]\" value=\"Volleyball\" \/><span class=\"wpcf7-list-item-label\">Volleyball<\/span><\/span><\/span><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n\t<div class=\"form-row clearfix\">\n\t\t<div class=\"column-half\">\n\t\t\t<p>Indoor<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"Indoor\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first\"><input type=\"checkbox\" name=\"Indoor[]\" value=\"Crafting\" \/><span class=\"wpcf7-list-item-label\">Crafting<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"Indoor[]\" value=\"TV\" \/><span class=\"wpcf7-list-item-label\">TV<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"Indoor[]\" value=\"Video\" \/><span class=\"wpcf7-list-item-label\">Video<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"Indoor[]\" value=\"Music\" \/><span class=\"wpcf7-list-item-label\">Music<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"Indoor[]\" value=\"Reading\" \/><span class=\"wpcf7-list-item-label\">Reading<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"Indoor[]\" value=\"Video Gaming\" \/><span class=\"wpcf7-list-item-label\">Video Gaming<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"Indoor[]\" value=\"Card Playing\" \/><span class=\"wpcf7-list-item-label\">Card Playing<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"Indoor[]\" value=\"Puzzles\" \/><span class=\"wpcf7-list-item-label\">Puzzles<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"Indoor[]\" value=\"Woodworking\" \/><span class=\"wpcf7-list-item-label\">Woodworking<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"Indoor[]\" value=\"Painting\" \/><span class=\"wpcf7-list-item-label\">Painting<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"checkbox\" name=\"Indoor[]\" value=\"Shopping\" \/><span class=\"wpcf7-list-item-label\">Shopping<\/span><\/span><\/span><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n\t<div class=\"form-row clearfix\">\n\t\t<div class=\"column-half\">\n\t\t\t<p>Do you wear contacts?<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"con1\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"con1\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"con1\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"column-half\">\n\t\t\t<p>Interested<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"conYes\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"conYes\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"conYes\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n\t<div class=\"form-row clearfix\">\n\t\t<div class=\"column-full\">\n\t\t\t<p>Current Contact Lens Wearers: Any Issues:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"Issues\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"Issues\" \/><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n\t<div class=\"form-row clearfix\">\n\t\t<div class=\"column-half\">\n\t\t\t<p>What is most important to you?<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"important\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first\"><input type=\"checkbox\" name=\"important[]\" value=\"Comfort\" \/><span class=\"wpcf7-list-item-label\">Comfort<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"important[]\" value=\"Updating Your Look\" \/><span class=\"wpcf7-list-item-label\">Updating Your Look<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"important[]\" value=\"Eyewear Wardrobe\" \/><span class=\"wpcf7-list-item-label\">Eyewear Wardrobe<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"important[]\" value=\"Thin Lens\" \/><span class=\"wpcf7-list-item-label\">Thin Lens<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"important[]\" value=\"Backup Pair\" \/><span class=\"wpcf7-list-item-label\">Backup Pair<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"important[]\" value=\"Optimized Vision\" \/><span class=\"wpcf7-list-item-label\">Optimized Vision<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"important[]\" value=\"Current Lens Technology\" \/><span class=\"wpcf7-list-item-label\">Current Lens Technology<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"important[]\" value=\"Glare Reduction\" \/><span class=\"wpcf7-list-item-label\">Glare Reduction<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"checkbox\" name=\"important[]\" value=\"Melanoma Prevention\" \/><span class=\"wpcf7-list-item-label\">Melanoma Prevention<\/span><\/span><\/span><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"column-half\">\n\t\t\t<p>Do you have more than one pair of glasses?<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"glassesPair\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"glassesPair\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"glassesPair\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n\t<div class=\"form-row clearfix\">\n\t\t<div class=\"column-half\">\n\t\t\t<p>Eyeglasses: Do you have more than one pair of current rx eyewear <span class=\"wpcf7-form-control-wrap\" data-name=\"rx\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"rx\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"rx\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"column-half\">\n\t\t\t<p>Eyeglasses <span class=\"wpcf7-form-control-wrap\" data-name=\"rxImp\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first\"><input type=\"checkbox\" name=\"rxImp[]\" value=\"Computer\" \/><span class=\"wpcf7-list-item-label\">Computer<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"rxImp[]\" value=\"Sunwear\" \/><span class=\"wpcf7-list-item-label\">Sunwear<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"rxImp[]\" value=\"Sports\/Hobby\" \/><span class=\"wpcf7-list-item-label\">Sports\/Hobby<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"checkbox\" name=\"rxImp[]\" value=\"Everyday Luxury\" \/><span class=\"wpcf7-list-item-label\">Everyday Luxury<\/span><\/span><\/span><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n\t<div class=\"clearfix\" >\n\t<\/div>\n\t<div class=\"form-row\">\n\t\t<div class=\"column-full gdpr-acceptance\">\n\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"acceptance-138\"><span class=\"wpcf7-form-control wpcf7-acceptance\"><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"acceptance-138\" value=\"1\" class=\"gdpr\" aria-invalid=\"false\" \/><span class=\"wpcf7-list-item-label\">By clicking, you are giving consent to your data being stored in line with the guidelines set out in our <a href=\"\/guyana\/privacy\" target=\"_blank\">Privacy Policy<\/a><\/span><\/label><\/span><\/span><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n\t<div class=\"clearfix\" >\n\t<\/div>\n\t<div class=\"form-row clearfix\">\n\t\t<div class=\"column-half\">\n\t\t\n\t\t<\/div>\n\t<\/div>\n\t<div class=\"form-row clearfix\">\n\t\t<div class=\"column-full\">\n\t\t\t<p><input class=\"wpcf7-form-control wpcf7-submit has-spinner\" type=\"submit\" value=\"Send\" \/>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n<\/div><!--end responsive-form--><div class=\"wpcf7-response-output\" aria-hidden=\"true\"><\/div>\n<\/form>\n<\/div>\n\n","protected":false},"excerpt":{"rendered":"* These fields are Mandatory First Name* Last Name* Email:* Confirm email:* Area* Guyana +592Afghanistan +93Albania +355Algeria +213American Samoa +1684Andorra +376Angola +244Anguilla +1264Antarctica +672Antigua and Barbuda +1-268Argentina +54Armenia +374Aruba +297Australia +61Austria +43Azerbaijan +994Bahamas +1242Bahrain +973Bangladesh +880Barbados +1246Belarus +375Belgium +32Belize +501Benin<span class=\"read_more_area\"><a class=\"read-more\" href=\"https:\/\/courtsoptical.com\/guyana\/patient-form\/\"> Continue Reading <\/a><\/span>","protected":false},"author":382,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"page-fullwidth.php","meta":{"_acf_changed":false,"footnotes":""},"class_list":["post-3168","page","type-page","status-publish","hentry"],"acf":[],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v27.0 - https:\/\/yoast.com\/product\/yoast-seo-wordpress\/ -->\n<title>Patient Form - Courts Optical Guyana | Eye Exam Optometrist &amp; Vision Care Center In Guyana<\/title>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/courtsoptical.com\/guyana\/patient-form\/\" \/>\n<meta property=\"og:locale\" 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