Title *

First Name *

Last Name *

Gender *  Male Female

Email Address *

Postcode *

Best Contact Number *  

Age group? *

Under 18 18-45 years 45-55 years Over 55 years

When do you wear glasses/contact lenses? *

All the time Only for reading Only for distance I don't wear glasses but suffer from poor vision

Do you have astigmatism? *

Yes No Not Sure

Has your prescription changed in the last 12 months?

Yes No Not Sure

Do you have any other eye conditions?

Glaucoma Dry eyes Keratoconus Corneal Scarring Cataracts Ocular herpes Retinal disease
Not sure None of the above

Have you had forms of eye surgery?

Yes No

What is your main motivation for seeking vision correction?

Lifestyle – I find my glasses/contact lenses inconvenient when performing activities
Safety – My glasses or contact lenses are affecting my safety
Freedom – I do not want to be dependent on glasses and contact lenses
Cosmetic – I look much better without my glasses
Discomfort – I find my glasses or contact lenses uncomfortable
Career – My job requires me to be able to see without glasses or contact lenses
Cost – I save more money without glasses or contact lenses

How soon are you thinking of having your vision corrected?

As soon as possible 1 - 3 months 3 - 6 months 6 - 12 months Undecided

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