Specialty Contact Lens Externship Interest Survey

Thank you for your interest in becoming a Specialty Contact Lens Externship Site. The Specialty Contact Lens Clinical Externship Committee was founded under GPLI (Gas Permeable Lens Institute) with the goal of identifying and adding new specialty contact lens externship sites for 4th-year optometric students. We appreciate your efforts and time as you take this next step, with the potential to expand your own practice, while simultaneously enriching education for future optometrists.

Survey responses will be reviewed and you will receive an email notification about your application status. Approved practices (along with contact information) will be compiled in a document and shared with optometry schools. Associated Colleges of Optometry may reach out to individual practices and specific requirements for any student externship rotation program must be agreed upon by both parties.

Thank you for your willingness to mentor, teach, and shape the future of optometry. We appreciate you!

Name: *
Email: *
Phone Number: *
Name and Address of Practice: *
Please provide a brief bio: *
What percentage of your schedule is dedicated to specialty contact lens services and complex anterior segment cases? *
How many NEW specialty contact lens fittings do you perform per week? *
What other specialty services does your practice provide? (Select all that apply) *
Required
Estimated percentage of examinations per week that include other specialty services selected above: *
What specialty contact lens modalities are prescribed at your practice? (Select all that apply) *
Required
*If you selected "Corneal Gas Permeable CLs" above, please indicate which specific lenses you fit below: (Select all that apply)
What equipment, specific to contact lenses, do you have in your practice? (Not an all-inclusive list; select all that apply) *
Required
Which CLMA laboratories do you actively utilize and work with (Select all that apply; see https://www.clma.net/docs/2022-CLMA-member-directory.pdf for reference): *
Required
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