Laser Eye Surgery Christchurch Lasik Eye Surgery Fendalton Eye Clinic Christchurch New Zealand

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HD LASIK� at Fendalton Eye Clinic

Request An Assessment

Please use this form to request your FREE LASIK Assessment. This is a 30 minute appointment with an experienced member of our technical team. A series of tests will be performed on your eyes.

We will then explain your specific focusing error and discuss with you whether or not it would be appropriate for you to proceed with corrective laser eye surgery.

Please note that this is to assess your suitability for LASIK eye surgery. It is NOT an eye examination.


1. Contact Details (note - Items in BOLD are required)

Your Full Name:
Date of Birth:	(DD/MM/YYYY)
Address:
City/Town:
Province/District:
Phone (Daytime):
Phone (Evening):	(If different from above)
Mobile Phone:
Fax:
Note: Please include area code in phone and fax numbers.
Email:

2. Assessment Details

I would like to request a FREE Eye Assessment as follows: (Please see our Assessment Calendar for Assessment dates in your location)
Location:
Date Requested:	Format Day-Month-Year (Use Calendar to select)
AM / PM Preference?	AM PM

Any Specific Questions or Comments:

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