About you

FIRST NAME *

LAST NAME *

EMAIL ADDRESS *

PHONE (Optional)

AGE RANGE *

What brought you here

MY PRIMARY INTEREST IN OLORIN *

ANYTHING YOU’D LIKE US TO KNOW (OPTIONAL)

A few quick health questions

These questions help us understand your health background so we can ensure Olorin is a good fit for you. If any responses suggest a wellness consultation would be helpful, someone from our team will reach out before you proceed. Please check any that apply. *

I have diabetes (Type 1 or Type 2)

I have an active autoimmune condition

I am currently undergoing cancer treatment or recently completed treatment

I am currently taking immunosuppressant medications

I take blood thinners (warfarin, Eliquis, Xarelto, or similar)

I am pregnant or breastfeeding

I had an ocular procedure in the last 6 months

None of the above apply to me

WELLNESS DISCLOSURE

Olorin is a science-based ocular wellness company. Our products are formulated to support long-term visual wellness and are not intended to diagnose, treat, cure, or prevent any disease or medical condition. We do not make medical claims, and Olorin is not a substitute for professional medical care. Results vary by individual. Everything about Olorin — what it is, how it works, and whether it makes sense for you — is waiting on the other side of this form. We just want to know a little about you first. By continuing, you confirm that you are seeking wellness information and that you will consult a qualified healthcare provider regarding any medical conditions you have.

These statements have not been evaluated by the Food and Drug Administration. This product is not intended to diagnose, treat, cure, or prevent any disease. Individual results may vary.

I have read and understand the Wellness Disclosure above. I understand thatOlorinn is a wellness experience and not a medical treatment. I consent to Olorin contacting me with my personalized Vision Wellness Information Guide and, if our team feels a brief wellness consultation would be helpful based on my responses, to reach out to arrange that.