Eye Health Services - Nike Maxsight

To determine if NIKE MAXSIGHT™ is right for you, please fill out this short questionnaire. One of our representatives will call you at your convenience.
First Name
Last Name
Street
City
	State Zip
Telephone	Ext
E-mail (required)
Call me as soon as possible Send me a free brochure
Call me between:
On this day
What sports/hobbies do you participate in? (Check all that apply.)
tennis		golf
skiing		softball/baseball
basketball		running
volleyball		shooting/hunting
biking		soccer
Other (specify)
What is your level of competition?
casual competitive elite
Do you require vision correction?
yes no
What type of vision correction do you wear during sports?
eyeglasses			prescription sunglasses
contact lenses			none
If you wear glasses/sunglasses during sports, do they ever: (check all that apply)
slide down your nose/fall off			hinder your peripheral vision
break/need adjustment			hurt/get uncomfortable
distract you/obscure vision			become dirty/fog up vision
If you wear contact lenses during sports, do you: (check all that apply)
have difficulty adapting your vision from sunlight to shade
become temporarily blinded from sunlight
have visual discomfort from glare/brightness
get headaches see glare squint
Are you interested in learning more about NIKE MAXSIGHT and how it can help make your sports experience more enjoyable?
yes no