Section 1: What Did You Buy / Get Quoted? Required

Section 2: Eyeglasses Details

Frame Brand (e.g., Ray-Ban, Coach, Oakley)

Frame Price ($)

Lens Type

Lens Price ($)

Lens Coatings / Add-ons (check all that apply)

Anti-Reflective (AR) Blue Light Blocking Photochromic / Transitions Scratch-Resistant UV Protection Polarized

Total Charged for Glasses ($)

Include frames + lenses + all add-ons

Contact Brand (e.g., Acuvue, Dailies)

Wear Schedule

Quantity / Supply

Price Paid ($)

Surgery Type

Price Quoted / Paid ($)

Is this price:

Per eye Both eyes total

City / Metro (for comparison)

What's included? (check all)

Pre-op evaluation Post-op visits (1 year) Wavefront/custom mapping Enhancement guarantee Medication/drops

Do you have vision insurance?

Medical eye conditions may be covered by your medical insurance instead of vision insurance — potentially saving hundreds.

Was any of this billed to medical insurance?

Do you have medical insurance?

Is this for a child under 19?