Pre-examination Questionnaire
(Updated 6th January 2021)
Thank you for choosing us for your eye care needs. We appreciate your patience in these unprecedented times.

Eye health and vision remain an important part of primary care, so we remain open (strictly by appointment only) for essential eyecare and all urgent eye problems while in Tier 4 restrictions and or National Lockdown.

Our governing bodies, NHS England and the College of Optometrists have advised that we currently remain in amber stage which is defined as 'Needs and/or symptoms led eye care as judged by a clinician. Outstanding routine eye care needs only as capacity permits'. To put it simply, this means if you have any concerns over your eyesight, eye health or glasses, we can still help.

We understand you may feel nervous about attending the practice but have strict measures in place to ensure the safety of both you and our staff. As of January 2021, our staff will be tested for Covid weekly. We wear PPE and have extensive cleaning schedules in place in between every patient we see. We are open by appointment only to limit the amount of people in the building at any one time.

To request your appointment, please take a few minutes to complete the following pre-examination questionnaire. It will take approximately 5-10 minutes to complete. The information we gather will be assessed by a member of our clinical team to assess the urgency of any symptoms or need . We will call you to arrange the most appropriate appointment type to best help you.

This form can be used to request appointments for eye examinations, contact lens fitting and check ups as well as to choose new glasses. You do not need to complete this form for repairs or adjustments, please call 0208 293 9493 or email to arrange this.

This form also asks some questions about your eye history and lifestyle. Providing this information ahead of your appointment allows us to ensure any existing information held on file is up to date. It also helps us to prepare for your appointment and minimise the time spent in close contact in the consultation room.

If you are completing on behalf of a child or someone you care for, please complete with their information. If you need to book for more than one person, you will need to complete a questionnaire for each person.

What happens next:

A member of our support team will be in contact as soon as possible to arrange a suitable appointment.

Your Optometrist may decide to call you to discuss some of your answers ahead of your appointment.

Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy