Incident Report
RequiredRequired Question(s)
Required 1.

Date of incident:

 

50 characters left.
Required 2.

Are you a client or an optician? 

Client
Optician
Required 3.

Are you under 19 or over 65?

Under 19
Over 65
Other  
Required 4.
Do you receive assistance from the Ministry of Social Development?
Yes
No
  • Comment:

  • 500 characters left.
5.
Please enter the information indicated below.

First Name:
Last Name:
Work Phone:
Home Phone:
Email Address:
emailaddress@xyz.com
City:

Required 6.

I am reporting an incident pertaining to:

Eyewear purchased through online sellers
Eyewear purchased at a retail location
Cosmetic contact lenses purchased through online sellers or a retail location
Other  
  • Comment:

  • 500 characters left.
7.

The glasses are not working because (please select all that apply):

Improper fit of glasses (for example, the glasses fall off my face or they're sitting crooked
Can't see
Did not receive follow-up or after care services after eyewear was provided
Other  
  • Comment:

  • 500 characters left.
8.

The contact lenses are not working because (please select all that apply):

Improper fit of contact lenses (for example, my contact lenses keep falling out or are scratching my eye)
Can't see
Inability to insert & remove contact lenses
Experiencing discomfort from contact lenses
Did not receive follow-up or after care services after eyewear was provided
Other  
  • Comment:

  • 500 characters left.
Required 9.

Were you provided a refund for your eyewear?

 

50 characters left.
10.

Please provide any additional information regarding the incident, defect, or problem:

 

1000 characters left.