Are you having any problems with your vision?
[ ] Yes
[ ] No

If yes:
[ ] Far Away
[ ] Close Up
[ ] In Between

# LensCrafters

EFTA02314187

<table><tr><th>COMPLETE SG
POLYCARB WITH SG AR</th><th></th></tr><tr><td>COMPLETE
POLYCARB WITH A/R</td><td></td></tr><tr><td>PLUS
POLYCARB HARDCOTE</td><td></td></tr><tr><td>POLYCARB</td><td>LENS</td></tr><tr><td>SPF
POLYCARB POLARIZED</td><td>MATERIAL</td></tr><tr><td>POLARIZE POLYCARB</td><td></td></tr><tr><td>SNETTIVO
UV &amp; TINT</td><td></td></tr><tr><td>DURALENS
CR39 HARDCOTE</td><td></td></tr></table>

EFTA_R1_01205761

# LensCrafters (cont.)

## What type of work do you do?

1199 FIRST AVENUE
1199 FIRST AVENUE AT 65TH STREET
NEW YORK, NY 10021
Phone: (212) 744-5149
Fax: (212) 744-5176
Patient Name: Jeffrey Epstein
Date: 9/2/10
Sun:

<signature> Fax: (212) 744-5176
Jeffrey Epstein
Date: 9/2/10

Do you use a computer?
[ ] Yes
[ ] No

Reading:
[ ] Extended Reading
[ ] Very Close/Fine Detail

Do you have problems with bright lights or glare?
[ ] Yes
[ ] No

If yes, when do you notice this?
[ ] On-coming headlights
[ ] Computer Screen
[ ] Glare from windshield
[ ] Sunlight

What sun protection do you currently wear?
<empty>

What hobbies/activities do you enjoy?
<empty>

Do you engage in any activities that could cause eye injury?
<empty>

Are you currently a contact lens wearer?
[ ] Yes
What do you like [Y] dislike [N] about your contacts?
[ ] Vision
[ ] Comfort
[ ] Convenience
[ ] Dryness
[ ] No
Have you ever worn contacts? [Y] [N]
Do glasses get in the way of any activities? (golf, swimming, etc.)
<empty>

Would you like to explore the latest advances in contact lenses?
[ ] Yes
[ ] No

What do you like [Y] dislike [N] about your current eyewear?
[ ] Weight
[ ] Thickness
[ ] Fit
[ ] Style
[ ] Shape
[ ] Durability
[ ] Size
[ ] Color

White Copy -- Patient Yellow Copy -- Dispenser Pink Copy -- File
EX-067-LC

Sun:
OD:
Sphere: +1.75
OS:
Sphere: +2.25

Work/Primary:
OD:
Sphere: +1.75
OS:
Sphere: +2.25

Computer:
<signature>
OD:
Sphere: +4.00
OS:
Sphere: +4.50

Safety/Specialty:
OD:
Sphere: <empty>
OS:
Sphere: <empty>

<signature>
OD License # <signature>

<table><tr><th></th><th>Sphere</th><th>Cylinder</th><th>Axis</th><th>Prism</th><th>Add</th><th></th><th>Single Vision</th><th></th><th></th><th></th></tr><tr><td>OD</td><td>+1.75</td><td></td><td></td><td></td><td></td><td>[ ]
[ ]</td><td>[Progressive
Bifocal
Trifocal</td><td></td><td></td><td></td></tr><tr><td>os</td><td>17.25-0.25</td><td></td><td>090</td><td></td><td></td><td></td><td>Distance
Near</td><td></td><td></td><td></td></tr></table>

OD:
Sphere: +1.75
Cylinder: <empty>
Axis: <empty>
Prism: <empty>
Add: <empty>

OS:
Sphere: +2.25
Cylinder: -0.25
Axis: 070
Prism: <empty>
Add: <empty>

[x] Single Vision
[ ] Progressive
[ ] Bifocal
[ ] Trifocal
[ ] Distance
[ ] Near

Computer: reading

8

<table><tr><th></th><th>Sphere</th><th>Cylinder</th><th>Axis</th><th>Prism</th><th>Add 1</th><th>Add 2</th><th rowspan="3">Single Vision
Progressive
PRIO
[] Bifocal</th><th rowspan="3"></th><th rowspan="3"></th><th rowspan="3"></th><th rowspan="3"></th><th rowspan="3"></th><th></th></tr><tr><td>OD</td><td>+4.00</td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>OS</td><td>+4.50</td><td>-0.25</td><td>090</td><td></td><td></td><td></td><td></td></tr></table>

OD:
Sphere: <empty>
Cylinder: <empty>
Axis: <empty>
Prism: <empty>
Add: <empty>

OS:
Sphere: <empty>
Cylinder: <empty>
Axis: <empty>
Prism: <empty>
Add: <empty>

[ ] Single Vision
[ ] Progressive
[ ] Bifocal
[ ] Trifocal
[ ] Distance
[ ] Near

JAY Yoon O.D.
OD License # 7467 Expires: 9 / 1 / 11

Match Prior:
BC [ ] Yes [ ] No
OC [ ] Yes [ ] No

PD <empty> / <empty> mm

Remarks:
<empty>

CP#3008024

<signature> Jay Yoon O.D.