What is your age group?*  under 20 20-39 40-59 60+

Age you started wearing glasses?*  Under 20 Over 20 Over 40

Have you noticed any deterioration of your vision in the last 5 years?* Yes No

Is your vision: (check all that apply)* Blurry or cloudy Halos around lights and/or over-sensitivity to light Poor at night Double or multiple images in one eye Not as colorful or vibrant as it used to be None of the above

Your prescription - are you:*  Shortsighted Farsighted Astigmatic None of the above

Do you use readers or bifocals?*  Yes No

Is it most important to you to have (check all that apply):*  Good distance vision (sporting activities, driving, etc) Good medium distance vision (general activities) Good close-up vision (reading, computer work, etc) All of the above

If you required cataract surgery would it be important for you afterwards to be lens-free?*  Yes No

Please provide us with your contact information: