Pediatric Registration Form

Gender*

* Check Preference

Does your child wear glasses?*

When does your child wear glasses?

Does your child wear contact lenses?*

Does your child have any of the following? (select all that apply)

Any complications during pregnancy or delivery?

Has your child undergone any of the following testing/treatment? (check all that apply)

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

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

Does your child drive?*

Does your child wear sunglasses?*

Does your child use nicotine products?*

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