To start, please tell us how old you are:

Under 18

19-39

40-55

56+

Have you ever been told you have astigmatism?

Yes

No

Do you have to wear glasses/contacts for...?

Driving

Computer

Reading

All of the above

Have you had any of the following procedures on your eyes (LASIK, PRK, RK, Cataract Surgery)?

Yes

No

Do you suffer from multiple sclerosis, lupus, keratoconus or diabetic retinopathy?

Yes

No

What email should we send the results to?

What is your first name?

What is your last name?

What phone number can we use to call/text you?

I agree to receive SMS text messages from RLE Vision

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