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Vision Prescription Study
Amber Farwig
2025-04-09T15:03:26-04:00
Do you wear prescription glasses or contact lenses?
This form is for individuals who have been asked to re-upload their prescription. Please do not share this link.
Are you 18 years of age or older?
(Required)
Yes
No
This form may only be completed by adults 18 years of age or older.
You may only submit a prescription on behalf of yourself or a minor for whom you are the legal guardian.
(Required)
I am submitting my own prescription
I am submitting a prescription on behalf of a minor
First Name
(Required)
Last Name
(Required)
Email
(Required)
The gift card for completing this survey will be sent via email.
Please provide your state and country of residence:
(Required)
State
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cabo Verde
Cambodia
Cameroon
Canada
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo
Congo, Democratic Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czechia
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic People's Republic of
Korea, Republic of
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Macedonia
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russian Federation
Rwanda
Réunion
Saint Barthélemy
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Sweden
Switzerland
Syria Arab Republic
Taiwan
Tajikistan
Tanzania, the United Republic of
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkmenistan
Turks and Caicos Islands
Tuvalu
Türkiye
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Viet Nam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Country
What type of prescription are you uploading to this form?
(Required)
Prescription Glasses: Single Vision
Prescription Glasses: Progressive Lenses
Contact Lenses
This field is hidden when viewing the form
What type of prescription are you uploading to this form?
Prescription Glasses: Single Vision
Prescription Glasses: Progressive Lenses
File
(Required)
Accepted file types: png, jpg, jpeg, pdf, gif, doc, docx, Max. file size: 50 MB.
NOTE: If you are having trouble uploading your file from a mobile device, please try using a laptop or desktop. If you require assistance, email us at
[email protected]
By submitting this form, you agree to the following terms and conditions:
(Required)
I agree to the privacy policy.
1. Data Collection and Storage: You consent to the collection and storage of your optical prescription data, including images of valid optical prescriptions issued by optometrists from private practices or optical retail. The data collected will include the prescription document, patient's country and state, and prescription type (glasses or contacts).
2. Data Transmission: You consent to the transmission of your optical prescription data to our secure servers for processing and analysis. This data may be shared with authorized personnel involved in the project.
3. Data Redaction: You acknowledge that any personally identifiable information (PII) such as name, address, and phone number will be redacted from the prescription image to protect your privacy.
4. Data Usage: The collected data will be used solely for the purpose of collecting a diverse set of optical prescriptions, with a mix of single vision, progressive Rx, and contact lenses. The data will be analyzed to meet the project's objectives and will not be used for any other purposes without your explicit consent.
5. Prescription Criteria: The data collected will include prescription glasses (single vision and progressive) and contact lenses, with the required prescription details such as issuance or expiration date, prescription values (sphere, cylinder, axis, etc.), and prescribing doctor information.
By clicking "I agree to the privacy policy," you confirm that you have read, understood, and agree to the terms and conditions outlined above.
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