MYeyes Intoduction Form

Please print:-

Dear Practitioner,
The bearer of this introduction form would like the information required to purchase contact lenses.
( please visit www.myeyes.co.uk)

Send to:-

Fax:- 020 8530 6246
Address:
135a George Lane,
South Woodford, E18 1AN

Your Name:-
Address:-
Telephone Number:-
Email Address:-

You will be requested to pay for an eye examination and/ or a contact lens consultation. The cost will be determined by your wearing schedule and the level of aftercare.

CONTACT LENS SPECIFICATION:-

  Type Base Curve Diameter Power
Right        
Left        
Colour:-

Practitioner Details:-

 

Signature :-

Please provide as much information as possible including email address for future use.