Name
*
If you're contacting us on behalf of someone else, please enter their name here and include your own in your message.
First Name
Last Name
Phone number
*
Email address
*
GP & surgery name
Reason for requesting an eye examination
*
Please tick all that apply
Eye conditions you're aware of:
Please give details as best you can of any conditions such as diabetes, macular degeneration or glaucoma, along with details of any hospital treatment for them (or diabetic screening visits).
Examination type
*
It's difficult for me to get out to an optician unassisted because:
*
Please tick all that apply
Do you (or your partner) claim any of the following?
At home there is:
*
If there's a smoker at home, the room for us to test in needs to be fully ventilated in advance. If there's a cat or a dog around, they will need to be in a separate room away from our equipment and clinicians. Thank you for your understanding and cooperation.
Message
*
If you're requesting for someone else, please give your own name and contact details, let us know if you're planning on being at the appointment, and please confirm whether or not the person has any issues with mental capacity or ability to give consent.
