Pre-Appointment Survey

Your details

First Name *

Last Name *

Date of Birth *

Phone

Your Interests

What sports, interests or hobbies do you enjoy? This may be related to your eyecare solution.

Your Visual Environment

Where do you work or study? Also how far away in cm are your digital devices from your eyes?

When was the last time you had your eyes examined?

e.g. 22 May, 2019

Where was your last eye examination carried out?

e.g. Peter Dick Optometrists

Other

General Health Issues

Do you have any health issues? Please list your prescribed medications. They may affect your eyes.

Other

How did you hear about us?