Your Email (required):
Mobile (required):
Preferred method of contact: MobileEmail
Are you: Existing client? New client?
Do you require: Eye test? Contact lenses? Any other special considerations?
Do morning or evening appointments suit you better?: (We will contact you during office hours to confirm a time)
Words move? Yes No
Words merge? Yes No
Pattern or shadows in text (like "rivers")? Yes No
Text appearing to stand out in 3-D above the page? Yes No
Words or letters fade or darken? Yes No
Discomfort with certain artificial lights and flicker? Yes No
Yes No
Reading for a long time: Yes No
Reading for a short time: Yes No
Looking in the distance for a long time: Yes No
Looking in the distance for a short time: Yes No
Hold reading unusually close/far away: Yes No
Close or cover one eye: Yes No
Frequently rub the eye(s): Yes No
Blink excessively: Yes No
Tilt head when reading or writing: Yes No
Move head when reading: Yes No
Use finger as marker: Yes No
Confuse letters or words: Yes No
Reverse letters or words: Yes No
Skip or omit words or lines: Yes No
Read slowly: Yes No
Tire easily/short attention span: Yes No
Poor general coordination: Yes No
Light Sensitive: Yes No
