Contact Lens Trial Evaluation
Please complete this form to evaluate your experience with the trial contact lenses.
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Date of Trial
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Contact Lens Brand
*
Please Select
Acuvue
Air Optix
Biofinity
Bausch + Lomb
Other
Lens Type
*
Daily
Bi-weekly
Monthly
Toric
Multifocal
Other
Please rate the following aspects of your trial experience:
*
Rows
Poor
Fair
Good
Very Good
Excellent
Overall comfort
1
2
3
4
5
Vision clarity
6
7
8
9
10
Ease of insertion/removal
11
12
13
14
15
Lens stability
16
17
18
19
20
End-of-day comfort
21
22
23
24
25
Did you experience any of the following while wearing the trial lenses?
*
Redness
Dryness
Irritation
Blurred vision
No issues
Other
How many hours per day did you wear the trial lenses?
*
Would you consider using these lenses in the future?
*
Yes
No
Undecided
Additional comments or suggestions
Submit Evaluation
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