Booking Form - Laser Vision Correction Assessment

We offer a FREE, no obligation suitability assessment: we will thoroughly examine and measure your eyes, and discuss the options that will suit your lifestyle and your eyes.

To make a booking, complete our online booking form below or call 1300 683 937 [1300 NuEyes], and one of our refractive surgery consultants will contact with you within 48 hours to schedule your personalised appointment. Please fill in all fields marked with an asterisk.

Title:

First Name:

Last Name:

Date of Birth:

Gender:

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Address Details

Street:

Suburb/Town/City:

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Postcode:

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Best Contact number:

Phone (day)

Phone (night)

Phone Number (day):

Phone Number (night):

About your current vision

	I wear glasses		I use contact lenses
	I use reading glasses		I am shortsighted (myopic)
	I am longsighted (hyperopic)		I have astigmatism
	I have cataracts		I have had cataract surgery and still wear glasses

Other Information

Why are you considering treatment?
When are you considering treatment?	1-3 3-6 6-12 months
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Nearest PersonalEYES location:	view locations >>
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