The Contact Lens Practice, Birmingham, UK

Laser & Eye Surgery

Not always as good as the claims!

Contact Lens Practitioners and Optometrists

Pre-Consultation Questionnaire

BEFORE YOUR CONSULTATION FOR AN ASSESSMENT PLEASE COMPLETE AND EMAIL US THIS SHORT QUESTIONNAIRE.

Contact Lenses should never be supplied without a detailed and extensive examination of the eyes carried out by a dedicated Contact Lens Specialist - not all Opticians are legally qualified to fit or supply contacts.

Therefore before we fit you with Contacts it is vital that we gain a full history of your eyes, your general health as well as your visual needs both at work and at play - all have a bearing on the final choice of lens design we advise most suitable for your individual clinical needs.

Please complete this form and email it to us before your initial Contact Lens Assessment to assist us us compiling your record card.

When most new patients visit they are surprised at the array of specialist equipment we utilise to gain the fullest details of your eyes and their shape etc.

You' ll see what we mean if you click here to see the basic equipment in our instrument room!

In a SPECIALIST practice like ours you should allow at least 2 hours for your initial consultation.

Fields marked * are mandatory

Personal information

ID number *

Title *

First name *

Surname *

Full address *

Postcode *

Email address *

Date of birth

Telephone (Home)

Telephone (Mobile)

Telephone (Work)

Occupation

Contact lens history

Your doctor's name

Your doctor's address

Approximately how long ago was your last eye test: years months ago.

The optician's name

Have you been fitted with contact lenses in the past?

	Yes
	No

Did they work to your satisfaction?

	Yes
	No
	N/a

Name of the optician who fitten them

What type of lenses were they?

Were the lenses

What BRANDS were worn?

Heath history

It is dangerous to fit lenses without full medical and ocular details. Very few conditions preclude fitting. Many suggest a specific lens material or type of fitting.

To reassure you. Lots of 'ticks' do not mean you are unsuitable. A final decision is only possible after a tolerance trial.

Please place a tick in the appropriate box should you at present, or in the past, have suffered with any of the following conditions. Should there be any other points which you think relevant, please add these at the bottom under "any other details".

Please tick all that apply

Any other details

Further information

Do you partake in any sports?

	Yes
	No

If yes, what are they

Do you wear glasses

	Constantly
	Occasionally
	Never

Did you find us by

If 'other', 'advert' or 'optician' please give further details

If recommended we like to say thank you so please give details if known.

Your referrer's name

Your referrer's address

Recommend a friend

If you know someone who's dissatisfied with contact lenses we can probably help them. Please fill in the following details so we may send them our booklet.

Do you know anyone dissatisfied with contact lenses?

	Yes
	No

Your friend's name

Your friend's address

Your friend's telephone

CONFIDENTIALITY
All personal and clinical information is treated in strict confidence. No detail of your case history will be given to anyone except with your written permission.

Please click on the following putton to send this information to our staff.

Our Vision is Your Vision

Our Vision is to introduce our patients to the freedom and pleasures of life without glasses. Specialists for over 35 years we have the expertise to fit those others consider unfittable.