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* 1. Please enter your contact information:

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* 2. Doctor's Name

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* 3. Do you have insurance that covers contact lenses?

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* 4. What eye condition have you been diagnosed with?

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* 5. Do you currently wear contact lenses?

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* 6. If yes, what type of contact lenses do you wear?

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* 7. On a scale of 1 to 5, how happy are you with your current lenses?

  Very unhappy Unhappy Satisfied Happy Very happy
Please rate your level of satisfaction:

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* 8. If you are unhappy, what are you unhappy about? (Choose all that apply).

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* 9. How does your condition impact your life?

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* 10. How do you think UltraHealth lenses would make a difference in your life?

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* 11. Please detail your financial hardship and why you should be selected to receive free UltraHealth lenses?

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* 12. How did you hear about the Sharing Vision Grant Program? (Choose all that apply).

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* 13. How did you hear about UltraHealth Lenses? (Choose all that apply).

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* 14. By submitting this application, you are stating that the facts set forth in it are true and complete. If you are accepted as a grant recipient and any or all of your application is found to be false, you will be required to repay for the services offered.

By submitting this application you agree to allow SynergEyes, Inc. to use any or all of your story for marketing purposes.

Per the terms of the Grant Program, within two months of wear, you are required to provide a testimonial as well as complete a brief online survey. Upon survey completion and receipt of your testimonial, SynergEyes will send the remaining lenses to your practitioner to complete your annual supply.

This program is currently open to legal residents of the 50 United States, Canada, Puerto Rico and District of Columbia.

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