调查问卷 - AchroLenses

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调查问卷

Fill in only in English/请用英语填写
Name of the person with Achromatopsia/色盲症患者姓名
Title/称谓*
First name/名*
Surname/姓*
Address/地址
Street Address/街道地址*
Address Line 2/更多地址详情
City/城市*
State/Province/Region/省/地区
ZIP/Postal Code/邮编*
Country/国家*
Email address/电子邮箱
*
Enter Email Confirm Email
Contact phone number/联系电话
Prefix/国家区号
Phone/电话*
About you/关于您的信息
Are you above 12 year old ?/您是否已满12周岁？
Age/年龄
At what age was the Achromatopsia diagnosed ?/几岁时确诊色盲症？
Has the Achromatopsia been confirmed by genetic test ?/色盲症是否已通过基因检测被确认？*
Do you use licensed eye care professional/ophthalmologist ?/您是否使用专业眼科护理人员/眼科医生的医疗服务？*
Do you wear tinted glasses ?/您是否佩戴有色眼镜？
If yes, what tint/color and brand ?/如果是，什么颜色与品牌？
Have you worn contact lenses before ?/您是否曾经佩戴过隐形眼镜？*
Have you worn tinted contact lenses before ?/您是否曾经佩戴过有色隐形眼镜？*
If yes, what tint/color and brand ?/如果是，什么颜色与品牌？
Do you need plano or prescribed contacts ?/您需要平光还是有度数的隐形眼镜？*
Do you have prescription for contact lenses ?/您是否有隐形眼镜的验光单？
- Shipping address other than above/采用与上述地址不同的其他邮寄地址
First name/名
Surname/姓*
Company
Street Address/街道地址*
Address Line 2/更多地址详情
City/城市*
State/Province/Region/省/地区
ZIP/Postal Code/邮编*
Country/国家*
Additional information you would like to provide/其他您想要提供的信息
File/文件
Max. file size: 512 MB.
Questions/问题
Acceptance/接受*
- 接受我们的隐私政策(…)以及条款和条件(…)