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Send Application Request For Personal Plan
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My First Name
*
My Main Eyesight Issue
Shortsighted (myopia)
Farsighted (hyperopia / presbyopia)
Astigmatism
Child Myopia
Other / Don’t Know
It’s ok if you don’t know! Use introduction field below to tell me about eyesight.
My Current Vision Correction
I Wear Glasses
I Wear Contact Lenses
I had Laser Surgery
I Need Reading Glasses (over 40 yrs old)
(check all that apply)
To Invite Why
My Vision Goals
Stop Eyes From Getting Worse
Reduce Eye Strain / Symptoms
Improve Eyesight
Get Rid Of Glasses Entirely
(check all that apply)
Why I Want To Get The Personal Plan
Jake takes on a very limited number of new participants each year. A quick introduction helps us choose cases.
Send Invite To My Email Address
*
* Your info is always kept private.
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