Full patient name
*
Patient email
*
Do they have a cataract or want RLE surgery?
Cataract
RLE
What is their visual acuity?
What is their refraction?
What is their intraocular pressure?
Do they have any pre-existing ocular pathology e.g Macular Degeneration or Glaucoma?
If yes, please add more information.
Have they had any previous laser refractive surgery?
Yes
No
Have they had any previous squint surgery?
Yes
No
Do they have Prism lenses in their glasses?
Yes
No
Optometrist name
*
Optometrist phone number
*
Optometrist email
*
Optometrist address
*
SUBMIT