Vision Correction Self Test

WHAT IS YOUR AGE?

Under 18

18 - 39

40 - 54

55+

DO YOU WEAR ANY OF THE FOLLOWING TYPES OF CORRECTIVE EYEWEAR?

Glasses

Contact lenses

A mix of glasses & contacts

Multifocal or progressive lenses

Readers

I don't use eyewear (but should)

WHAT IS YOUR VISION LIKE WITHOUT CORRECTIVE EYEWEAR?

Difficulty seeing far away

Difficulty seeing nearby

Difficulty seeing fine details or reading

Overall blurry vision

HAVE YOU EVER BEEN DIAGNOSED WITH ANY OF THE FOLLOWING?

Astigmatism

Cataracts

Macular degeneration (AMD)

An eye injury

Dry eye

Glaucoma

Diabetic eye disease

None of the above

(Check all that apply)

HAVE YOU HAD A VISION PRESCRIPTION CHANGE WITHIN THE LAST 12 CALENDAR MONTHS?

Yes

I'm Not Sure

PASS

Congratulations! From what you’ve told us, it sounds like you are an excellent candidate for Vision Correction Surgery, including LASIK, implantable contact lenses (ICL), Photorefractive keratectomy (PRK), or small incision lenticule extraction (SMILE) surgery. Schedule your consultation at Rosin Eyecare below to learn more about what these life-changing procedures can do for your vision.

Result

Name

Phone

NON-PASS

From your answers, it seems that you may not be an ideal candidate for Vision Correction Surgery — but that doesn’t mean that you don’t have other great options! Rosin Eyecare offers a number of exceptional vision correction alternatives to our surgeries. We recommend that if you’re interested in clearer vision, you should schedule a consultation to learn more about what we can do for your eyes.

Result

Name

Phone

Application for Employment Equal Oppurtunity Employer

Personal Data
Name*
Date
MM slash DD slash YYYY
Address
City
State
Zip Code
Home Phone*
Message Phone*
If Employed, can you provide proof US citizenship?
- Yes
- No
Position(s) applying for
Referred by
- AD
- Friend
- Relative
- Agency
- Other

Special Skills
Summarize any special skills o qualifications that you acquired through employment or other experience that are applicable to the job that you are applying for:
Employment History

Begin with most recent employer. Attach additional sheet if needed.
1. Employer
Date of Employment
Address
Phone
Ending Salary
Title/Duties
Manager's Name
Reason for Leaving
2. Employer
Date of Employment
Address
Phone
Ending Salary
Title/Duties
Manager's Name
Reason for Leaving
3. Employer
Date of Employment
Address
Phone
Ending Salary
Title/Duties
Manager's Name
Reason for Leaving

Personal Data
Have you been employed here before?
- Yes
- No
May we contact your previous employer?
- Yes
- No
Applicants Signature*
I certify that all of my answers giver here are trueand complete to the best of my knowledge, and that supplying false information herein shall result in immediate disqualification for employment or termination from employment, regardless of when such false information is discovered.
I authorize investigation of all statements contained in tis application for employment as may be necessary in arriving at an employment decision; and I hereby agree to indemnify and hold harmless each and every current or prior employer in defending against any charge, complaint or suit filed with any Federal, State or local agency, or in any court of the State or Federal government for providing an accurate, factual history of employment information.
I undestand that neither this document nor any offer of employment from the constitutes an employment contract, unless a specific document to that effect effect is executed by the employer and employee in writing.

Vision Correction Self Test

PASS

NON-PASS

Schedule a Free Consultation

Application for Employment Equal Oppurtunity Employer

Personal Data

Educational Record

High School

Trade or Technical Training

Trade or Technical Training

Special Skills

Employment History

Personal Data

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