lh20_Peepers Magnification Device Questionnaire

I am interested in*

Solar Shields are available in three colors and come in small, medium and large sizes. Once we receive your inquiry, a Peepers Technician will contact you to schedule an upcoming appointment for your solar shields fitting. When your appointment is scheduled, please bring your solar shields or sunglasses.

Once we receive your inquiry, a Peepers Technician will contact you to schedule an upcoming appointment. When your appointment is scheduled, please bring what you are currently using for magnification and an example of what you are trying to read.

Name*

First NameLast NameSuffix

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number*

Please enter a valid phone number.

Email*

example@example.com

What type of magnification device are you interested in? (Check all that apply)*

HandheldElectronicDesktopUnsure

What are you having trouble accomplishing at home?*

What do you want to do with your magnifier? Read a book, pay bills, read recipes, sewing, writing, etc.?*

What type of eye condition do you have?*

Do you currently wear solar shields or sunglasses?*

What type and why?

Please verify that you are human*