Title Select your title Ms Mrs Mr Dr *

First name *

Last name *

Age group Select an age group 20 ~ 30 years old 31 ~ 40 years old 41 ~ 50 years old 51 ~ 60 years old over 61 years old *

How should we contact you in order to confirm your appointment? Email
Telephone
*

Please enter your Email address *

Please enter your Telephone number *

What type of visual impairment(s) do you have? Myopia
Hyperopia
Presbyopia
Extreme Farsighted
Extreme Nearsighted
Cataracts
Glaucoma
Keratoconus
Dry Eye Syndrome
Not sure
*

Days available Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
*

Time(s) available Morning (8:00am to 12:00pm)
Afternoon (1:00pm to 4:00pm)
*

Comments/Questions

Have you ever had any surgical eye procedures before? Yes
No

What type of procedure have you previously had?

How did you hear about Valley Laser Eye Centre?

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