New Patients - Eye Examination - Bayfield and Bartlam

Seeing Is Believing

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If you would like to request an eye appointment online then please complete this form and we will contact you by telephone during working hours, Monday to Friday 9am-5pm (GMT) excluding Bank Holidays, to confirm your appointment.

Personal Details

* Title:
* Name:
* Surname:
* Date Of Birth:
Eg. DD/MM/YYYY
* E-mail:
* Daytime Tel:
Alternative Tel:
* Postcode:
Do you suffer from Diabetes?:
- Yes
- No
Do you suffer from Glaucoma?:
- Yes
- No

Appointment Details

Eye exam:
Contact lens fitting:
Contact lens 6 month checkup:
* First Appointment Date:
First Appointment Time:
- AM
- PM
- Anytime
Second Appointment Date:
Second Appointment Time:
- AM
- PM
- Anytime
Third Appointment Date:
Third Appointment Time:
- AM
- PM
- Anytime
* Select a practice for your appointment:
If you require a specific time for your appointment, please indicate below:

Your Last Exam

When was your last eye exam?:
Which Optician did you visit?:

Bayfield & Bartlam

Where did you hear about Bayfield & Bartlam?:
Bayfield & Bartlam respects your privacy and will not share your personal data with any third parties. Your details, including your name, address and e-mail address may be used by Bayfield & Bartlam to keep you informed about future products and services.
If you do not wish to receive such information please tick the box:

© 2008 Bayfield & Bartlam Opticians. All rights reserved.

Tel: 0113 275 1303
info@bayfieldandbartlam.co.uk
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