Scuba Mask -- HydroOptix - Online Application

	HydroOptix Registration Page for Eye Care Pros Dear Eye Care Professional, Thank you for your interest in joining our network of "Diving Doctors." Please take two minutes to fill out this application so that we can send new patients to your practice. HydroOptix will guard your information; we will not rent or sell your information to any commercial third parties. *Indicates fields that are required to be filled out in order to process your application.
1.	*^{Dr. Mr. Mrs. Ms.}
	Are you an: *Ophthalmologist Optometrist Optician
	*First Name

	Middle Initial

	*Last Name

	*Address 1

	Address 2

	*City

	*State/Province

	*Zip/Postal Code

	*Country

	*Phone

	*Fax

	*E-mail
	Please be sure your e-mail address is correct.
	Web site URL

	(Please double-check all the above for accuracy)
2.	*Are you a SCUBA diver? Yes No (If no, SKIP to #8)
	When were you first certified?
3.
4.	What organization(s) issued your certification card(s)? -- (Please check all that apply.)
	ANDI		NAUI
	BSAC		PADI
	CMAS		PDIC
	DIWA		SDI
	GUE		SSI
	IANTD		TDI
	IDEA		WASI
	L.A. COUNTY		YMCA
	MDEA		Other
	NACD
	NASDS
	NASE
5.	What is your highest SCUBA certification level? (For "equivalent" certifications, please check all that apply.)
	Resort		Divemaster
	OW Diver		Assistant Instructor
	Advanced Diver (navigation, night and deep)		Instructor
	Nitrox Diver		Instructor Trainer
	Rescue Diver		Other
	Advanced Rescue Diver
	Technical Diver
	Approximately how many dives per year do you make?
6.
	Approximate total number of dives you've made since your certification?
7.
8.	What is the name of your eye care practice?
9.	Are you the: Owner Partner Employee
	Please indicate the number of each type of eye-care professionals in your office.
10.	Ophthalmologists Optometrists Opticians
11.	Does your practice perform any type of refractive eye surgery? Yes No
12.	If so, what kind of surgery?
13.	Please indicate how many locations your practice has:
	What brands of contact lenses do you dispense? (Please check all that apply.)
14.	Bausch and Lomb	CibaVision	CooperVision
	Johnson and Johnson	Lifestyle
	Other
	Which brand(s) of disposable / frequent replacement contact lenses do you prefer? (Please check all that apply.)
15.	Bausch and Lomb	CibaVision
	CooperVision	Johnson and Johnson
	Other
	Please explain your preferences.
16.
17.	Do you dispense eyeglasses? Yes No
	To what professional associations do you belong? (Please check all that apply.)
18.	American Academy of Ophthalmology (AAO)		American Academy of Optometry (AAO)
	American Optometric Association (AOA)		American Society of Cataract & Refractive Surgery (ASCRS)
	Contact Lens Assoc. of Ophthalmologists (CLAO)		Contact Lens Council--Trade organization only (CLC)
	International Council of Ophthalmology (ICO)		International Federation of Opthalmologic Societies (IFOS)
	Japanese Ophthalmological Society		National Academy of Opticianry (NAO)
	Opticians Association of America (OAA)		Vitreous Society
	Contact Lens Society of America (CLSA)
	Other
	What is your personal experience wearing contact lenses?
19.	Don't wear contact lenses	Currently / frequently	Currently / NOT frequently	No longer wear contact lenses
	If you wear contact lenses and are a SCUBA diver, do you wear them while diving?
20.	Yes	No
21.	Is there a local SCUBA shop whom you would feel comfortable working with? We will contact them on your behalf to encourage synergistic referrals.
	Store Name

	Phone number

	Person to contact

	Thank you very much for taking the time to give us this valuable information. We look forward to sending you many new patients, and thank you for helping revolutionize underwater vision. The staff at HydroOptix
	We welcome any comments you may have, below:



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HydroOptix Registration Page for Eye Care Pros