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* 1. Are you at least 18 years of age?

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* 2. First Name:

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* 3. Last Name

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* 4. Preferred Name

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* 5. Email Address

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* 6. Phone Number

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* 7. Zip Code

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* 8. Do you currently wear prescription contact lenses?

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* 9. Have you ever been diagnosed with an irregular cornea?

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* 10. Are you able to travel to our Carlsbad, CA location, and would you be able to travel regularly for a period of up to 6 months?

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