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About You
Title*
First Name*
Last Name*
Date of Birth*
Gender*

Contact & Address
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Street Address*
Suburb/Town/City*
State*
Country*

Your current vision
About your current vision*
- I wear glasses
- I use contact lenses
- I use reading glasses
- I am shortsighted (myopic)
- I am longsighted (hyperopic)
- I have astigmatism
- I have cataracts
- I have had cataract surgery and still wear glasses

Other information
Why are you considering treatment?*
When are you considering treatment?*
Your Hobbies/Sports
Will you need help financing your procedure if you are deemed suitable?*
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