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Name (first and last) *

Date of Birth *

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Day

Year

Sex *

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Current Address *

Email *

Phone Number *

Please list the number we can best reach you at

What is the best way for us to contact you? *

What days would you be available to participate in a research study? *

Tell us a little about yourself

Tell us a little bit about yourself. Anything goes. Maximum 500 words.

When was your last eye exam? *

Within Past Year

Within Past 2 Years

Within past 3-4 Years

5 or more years ago

Don't Remember / Haven't Had an Eye Exam

Do you wear glasses (and) or contacts *

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