Name
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First Name
Last Name
Email
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example@example.com
Phone Number
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Please enter a valid phone number.
Postal Code
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Tell us (in 100 words or less) how you would spend your $5,000 to make the most of your summer adventure.
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Do you currently wear Contact Lenses?
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Please Select
Yes, I wear clariti® 1-day contact lenses
Yes, I wear other contact lenses
No, but I'm interested in trying contact lenses
No, I prefer glasses
No, I don’t need vision correction
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