Pre-Verification Form
Name
Last, First
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Address
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City
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State
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ZIP Code
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Phone Number
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Email Address
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Eye Exam?
Have you been to an eye doctor within the last year? If not, No problem! We will match you with a local eye doctor in time for the convention.
If Yes, Doctor's Name/Practice
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If Yes, Doctor's Phone Number
If not available, put N/A
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If Yes, Doctor's Fax Number
If not available, put N/A
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