Information Request

*Denotes a required field.

*Name:

*Address:

Address 2:

*City:

*State/Province:

*Country:

*Zip:

*Phone:

*Fax:

Email:

1. What subjects would you be most interested in related to refractive practice development?

Please rank the following from 1 to 5 (1 most important - 5 least important)
    Clinical Patient Care
    Advancing Technologies
    Marketing
    Staff Training
    Other:

2. How would you prefer to receive Continuing Education Credits?
   a. Live sessions national (tied to meetings)
   b. Live sessions regional (not tied to meetings)
   c. Internet
   d. Fax out/Mail in

3. How long have you been in practice?
   a. 0 - 5 years
   b. 6 - 10 years
   c. 11 - 20 years
   d. 20 + years

4. You are presently licensed for:
   a. Topical with glaucoma
   b. Topical without glaucoma
   c. All Topicals with orals.
   d. Other:

5. How many pharmaceutical prescriptions do you write per week?

6. How many contact lens prescriptions do you write per week?

7. How many complete exams do you perform per week?

8. How many refractive patients (not in eyes) do you see per month?
   a. 0 - 3
   b. 4 - 6
   c. 7 - 10
   d. Other:

9. How many total refractive patients have you managed to date?
   a. 0 - 20
   b. 21 - 50
   c. 50 - 100
   d. Other:

10. Which of the following instruments do you presently have in your practice? (Please list brand)

    a. Corneal Topography Unit
       No        Yes

       if yes, please describe:


    b. Computerized Refraction System
       No        Yes

       if yes, please describe:


    c. Optic Nerve/Retinal Topography Analyzer
       No        Yes

       if yes, please describe:


    d. Visual Field Unit
       No        Yes

       if yes, please describe:


    e. Pupillometer (e.g. Colvard)
       No        Yes

       if yes, please describe: