Tel: 01481 253755
email:
enquiries@ajwebster.com
Advanced Eye Care
www.guernseyopticians.com
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Please complete form below at least 48 hours prior to Eye Examination.
If you are experiencing any Covid symptoms, please do not attend the practice.
What's your full name and date of birth?
What’s first line of your address and post code?
What’s your telephone number and email address?
Please provide your Doctor's name or the practice you attend.
Please state your occupation and any hobbies or pastimes you have.
Date of last Eye Examination if at different practice.
Reason for visit?
Routine Eye Examination
New spectacles
Change in prescription or any other reason - (please give details of any symptoms, when they started, how long they last, how severe they are and any triggers)
Please tick the boxes below if you suffer from any of these symptoms, in the large box please supply details of how long you have had them, if they have worsened, how long the last and any triggers)
Flashing lights
Floaters right eye
Floaters left eye
Double vision
Do you suffer from headaches? (Please give details of type, when they started, what makes them worse, how long they last and position)
Do you wear contact lenses?
No - not interested
No - I am interested in trialling them
Yes - Daily disposables
Yes - Fortnightly
Yes - Monthly
Yes - Other
Date contact lenses last worn?
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