* These fields are Mandatory

    First Name*

    Last Name*

    Email:*

    Confirm email:*

    Area*

    Phone*

    Occupation*

    Branch*

    How many hours a day do you use the following:

    Computer/Tablet Smart Phone TV

    Drive Digital Equipment

    What do you do for fun? (tick as many that applies)

    Outdoor Leisure
    FishingGolfHikingHuntingSkiingMotorcycleWalkingGardeningYardworkBirdwatchingTravel

    Sports
    BasketballBikingFootballTennisBaseballRacket ballRunningSoccerSwimmingVolleyball

    Indoor
    CraftingTVVideoMusicReadingVideo GamingCard PlayingPuzzlesWoodworkingPaintingShopping

    Do you wear contacts?
    YesNo

    Interested
    YesNo

    Current Contact Lens Wearers: Any Issues:

    What is most important to you?
    ComfortUpdating Your LookEyewear WardrobeThin LensBackup PairOptimized VisionCurrent Lens TechnologyGlare ReductionMelanoma Prevention

    Do you have more than one pair of glasses?
    YesNo

    Eyeglasses: Do you have more than one pair of current rx eyewear YesNo

    Eyeglasses ComputerSunwearSports/HobbyEveryday Luxury