Log In
Menu
Home
Eye examinations
Adult eye examination
Children's eye examination
Contact lens consultation
Corporate eye tests
Eyewear
Frames by brand
Cutler and Gross
Eco
Oliver Peoples
Paul Smith
Vinylize
Ray-Ban
Wiliam Morris
Woow
Exclusive to Askew
Eyepetizer
Gambini
Monc
Sunglasses
Oliver Peoples
Paul Smith
Ray-Ban
Lenses
Spectacle lenses - by Essilor
Single vision
Occupational
Varifocal
Coatings
Contact lenses
Alcon
Bausch and Lomb
Coopervision
Johnson and Johnson
Help and advice
Eye problems
Dry eye syndrome
Blepharitis
Cateracts
Myopia (short-sightedness)
Astigmatism
Glaucoma
Useful links
NHS eye tests
Moorfields Eye Hospital
Contact us
close
×
Call Us
0207 249 6333
close
×
Search form
Search
Home
Book an appointment
Book an appointment
Book an appointment
Do you or any of your household have any symptoms of COVID-19
Yes
No
We are unable to offer appointments to anyone displaying symptoms of Covid-19.
Contact details
First Name
*
Last Name
*
Phone Number
*
Email
*
Date of birth
*
Your appointment
When was your last eye test?
Do you know your current lens prescription?
*
Yes
No
Left eye prescription
Right eye prescription
Are you booking for a routine check?
*
Yes
No
Reason for booking your appointment
*
Your eye health
Have you had any eye advice given to you by a GP or other health professional
*
Yes
No
What advice was given?
*
Have you ever exprienced any of the following
Eye pain
*
Yes
No
Which eyes give you eye pain?
*
Left eye
Right eye
Discomfort with bright light
*
Yes
No
Which eyes give you discomfort?
*
Left eye
Right eye
Recent Trauma to the eyes
*
Yes
No
Which eyes suffered trauma?
*
Left eye
Right eye
Distortion of your vision
*
Yes
No
Which eyes suffer from distortiion?
*
Left eye
Right eye
Recent Floaters
*
Yes
No
Which eyes do you get floaters in?
*
Left eye
Right eye
Red Eyes
*
Yes
No
Which eyes suffer from red eye?
*
Left eye
Right eye
Sudden changes in vision
*
Yes
No
Please describe sudden changes
*
Do you have any mediacal conditions or prescriptions?
*
Yes
No
Please describle the issues briefly
*
Headaches
*
Yes
No
Shadows in vision
*
Yes
No
Which eyes were affected?
*
Left eye
Right eye
Have you ever visited hospital for your eyes at any time
*
Yes
No
Have you ever been told you have had any of the following:
cateracts
*
Yes
No
Which eyes were affected with cateracts?
*
Left eye
Right eye
Wear & tear at the back of your eyes
*
Yes
No
Wear & tear at the back of your eyes eye
*
Left eye
Right eye
Macular Degeneration
*
Yes
No
Macular Degeneration eye
*
Left eye
Right eye
Glaucoma/raised pressure in your eyes
*
Yes
No
Which eyes were affected with glaucoma?
*
Left eye
Right eye
Any other eye conditions
*
Yes
No
Any other eye conditions note
Any family members had eye conditions
*
Yes
No
PLease describe family eye conditions
*