Myopia Control Evaluation Form

Is your child’s nearsightedness getting worse each year? Take this short quiz to find out how we can help slow it down.
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1. Has your child been diagnosed with nearsightedness (myopia)?
2. At what age did your child first need glasses or contact lenses?
3. Has your child’s prescription changed in the last 12 months?
4. How often does your child do near work (screen time, reading, homework)?
5. How much time does your child spend outdoors daily?
6. Does anyone in your family have high myopia (strong prescription or thick glasses)?
7. Please tell us a little about yourself and your child so we can follow up with personalized information:
Preferred contact method:
What’s your biggest concern about your child’s eyesight?
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