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| 1. | Do you wish to receive a FREE subscription to Eyecare Business? |
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| | What is the approximate number of employees in your company? (select only one) |
Yes, please auto-fill my contact information for other publication qualification forms.
| 2. | May we contact you via email? |
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| 3. | May we contact you via email on behalf of ophthalmic industry on topics pertinent to you? |
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| 4. | May we contact you via fax? |
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| 5. | Please check the ONE category that best describes your business/professional activity: (select only one) |
| 6. | What is the wholesale price range of the majority of the eyeglasses sold at your business? (select one only) |
| 7. | At your practice, of the spectacle lenses you dispense, what percentage are A/R coated? |
%
| 8. | What are the lens processing capabilities on-site at your business? (select all that apply) |
| 9. | Do you buy, specify, approve or influence the purchase of contact lenses? |
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| 10. | Do you fit contact lenses? |
Yes
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| 11. | In lieu of a signature, we require a personal identifier. To verify that you submitted this application please enter below in what state were you born: |
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| | Category of Position: (select only one) |
| | Type of Organization: (select only one) |
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What is your facility's average bed size? |
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What is your role in purchasing decisions? |
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