First Name*:
Last Name*:
Address*:
City*:
State*:
Zip*:
Phone*:
Email*:
Have you been diagnosed with*:	Eye infection (no specific diagnosis) Fungal Keratitis Keratitis
Did you use Bausch & Lomb Renu?*:	YesNo
Did you use some other contact lens solution?*:	YesNo
What do you believe the cause of Fungal Keratitis is?*:
Verification: