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Name
Mailing Address
Street Address
City
State
Zip
Telephone
Fax
E-mail Address
  Do you wear prescription eyeglasses?  
  Do you wear prescription sunglasses?  
  Do you wear non-prescription sunglasses?  
  Do you prefer frames with a designer name?  
  Do your glasses reflect your personality/status?  
  How often do you replace your eyeglasses?  
  How often do you replace your sunglasses?  
  How much do you spend on a pair of prescription eyeglasses (including lenses)?  
  How much do you spend on a pair of non-prescription sunglasses?  
  When was your last eye exam?  
  Do you wear contact lenses?  
  Do you wear disposable contact lenses?  

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Copyright © 2004    Absolutely Optical   All rights reserved.
Revised: March 27, 2008