Free Assessment
First Name: *
Last Name: *
Gender: *
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Male
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Age: *
Do you wear:
Contacts
Glasses
Both
Your eye condition:
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Myopia (short sightedness)
Hypermetropia (long sightedness)
Astigmatism (both short and long sightedness)
Presbyopia (the need for reading glasses only)
Cataracts
Unsure
What is your current prescriptions:
R
L
Your preferred consultation Day/Time: *
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AM
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Contact telephone number: *
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Mail address (if different from above):
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Preferred method of contact: *
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How did you hear about Canberra Eye Hospital Laser Centre:
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Please fill in if you have any questions prior to you free consultation:
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