Contact Lens Appointment Pretest Form

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

This helps us to know about your appointment

Surname *

First name *

Date of Birth *

YYYY

Mobile phone number *

Email *

Address *

Occupation *

GP or GP Surgery, Name and Address *

Why do need this appointment

regular check up

I feel my eyes have changed

Clear selection

Comfort in your contact lenses

very aware of contact lenses

can't feel the contact lenses

Clear selection

Can you see well

Everything is clear

Distance is blurred

reading is blurred

Clear selection

How long do you wear your contact lenses for

up to 6 hours

6-12 hours

socially/sport

Other:

Clear selection

If you have any specific issues or concerns that you would like to bring to the attention of the optician, please list them here:

Clear form

Never submit passwords through Google Forms.

This content is neither created nor endorsed by Google. - Terms of Service - Privacy Policy

Does this form look suspicious? Report