Ask A Question Form

* Salutation::	- Mr. Mrs. Ms.
* First Name:
* Last Name:
Middle Initial:
* Street Address:
Address (cont.):
* City:
* State/Province:
* Zip/Postal Code:
Island (Hawaii or Guam):	- Oahu Big Island Kauai Maui Guam N/A
Country:
* Cell Phone:
Work Phone:
* Evening  Phone:
* E-mail:
* confirm E-mail:
* Date of Birth (00/00/00):
Your Sex:	Male Female

Occupation (description):
Are you Military, DOD, or a Dependant:	Active duty Military
	DOD or DOD contract employee
	Military or DOD dependant

* What kind of correction do you currently wear:

- Glasses Bifocals or Progressive Glasses Soft Contacts Toric Soft Contacts (for astigmatisim) Hard Contacts (RGP) Reading Glasses only None

About how long have you worn glasses	# of years
Presbyopia (do you need reading glasses or bifocals)	Yes  No

If you have your prescription, please complete this section.  (e.g.: -4.25 -1.00 x 160, +1.50 )  contact lens power is entered under Sphere.only.

Sphere, Cylinder, Axis, Add OD=Right Eye @  OS=Left Eye @

To help us provide the best possible service kindly tell us how you heard about us:

Internet search
Referred by friend/co-worker or family member
Yellow Pages

Have you seen any of our advertisements (Please tell us where i.e.: Honolulu Advertiser, Star Bulletin, Mid week, a Military paper, TV or Radio...)

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