EmailMe Form - Suitability Check

1. Have you had any of the following procedures? (Select all that apply) *

2. Which statement best describes your need for glasses or contacts lenses? *

I need them to see well at all distances (near, far and in between)

I need them only when I am performing a near task such as reading a newspaper

I need them only when i am working on my computer

I need them to see street signs

Other

3. How often do you wear reading glasses to see near objects clearly? *

Frequently

Occasionally

Rarely

Never

4. Considering your professional life, please check the one activity you do most often. *

5. What are you most interested in at this time? *

I would like to reserve a seat at a KAMRA patient seminar to lean more

I would like to schedule a KAMRA consultation

I would like to have someone call me

Please add me to your mailing list

Other

Name *

First Last

Email *

Daytime Phone Number *

### - ### - ####

6. Your age *

Under 45

Between 45-50

Between 51-65

Over 65