Customer Information Survey

This information is used to set up your appointment and to mail you your prescription if you qualify.

First Name *

Last Name *

Email *

Phone *

Address *

City *

State *

Postal code *

Please choose your time zone *

Pick all that apply now and in the past *

How long have you had these issues *

How is this issue affecting your quality of life? *

Have you seen another doctor about this issue? *

List any medications that you are currently on.

Have you driven a car with tinted windows before? (Warning, window tint can restrict your ability to see in low light conditions.) *

Do you now, or have you had tinted windows in the past? *

Are you the intended driver or primary passenger of the vehicle that the prescription is being written for? *

Are you a licensed driver? *

Number of vehicles *

How did you hear about us?

I understand that MyEyeRx.net is not a window tint company and can not determine what is a safe level for my vision. That the recommendation for window shade/ tint is made based upon the information provided to the doctor and staff of MyEyeRx.net by myself. MyEyeRx.net is not responsible (liable) for actions taken by me or other parties operating my vehicle. All responsibilities and actions taken by the driver are that of operator of the vehicle/ of the driver/ owner of the vehicle including but not limited to operating in adequate lighting conditions. *

Captcha

I agree to terms & conditions and privacy policy provided by the company. By providing my phone number and email, I agree to receive text messages and emails from the business. I also acknowledge and agree that your consultation, conducted via a Zoom meeting with a doctor, will be recorded by default to ensure quality and for record-keeping purposes.