New Adult Registration Form

Gender*

Do you wear glasses?*

When do you wear the glasses?

Do your wear contact lenses?*

What problems are you having with your eyes? (select all that apply)

Are you interested in learning more about laser vision correction?

Are you pregnant or nursing?

Do you have any of the following eye conditions? (check all that apply)

Do you have any of the following medical conditions? (check all that apply)

Do you drive?*

Do you wear sunglasses?*

Do you consume alcohol?*

Do you use tobacco products?*

Do you consume narcotics?*

Living status*

Does anyone in your family have any of the following? (check all that apply)