Booking Form - Laser Vision Correction Assessment

Wake up to a new view this summer – $1000 off all-lasik laser vision correction*.

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:

* DD-MM-YYYY

Gender:

Male Female

Email Address:

*

Address Details

Street:

*

Suburb/Town/City:

*

State:

*

Postcode:

*

Country:

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
Hobbies/Sports:	*
Nearest PersonalEYES location:	view locations >>
How did you locate the PersonalEYES website?	*
I would like to receive email updates and news from PersonalEYES

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Booking & Information

Summer promotion

TERMS & CONDITIONS
*Offer is valued at $1,000 per person ($500 per eye) and is valid for all-laser vision correction at any personalEYES Centre in NSW. To qualify for the special offer you must have your surgery before the 28th February 2012. Book now for your free suitability assessment.