Appointment request form

Name

First Line of home address

Contact number

Which practice would you like to visit?

Thame

Wendover

Chinnor

I would like to request an...

Optometry Appointment (please complete below questions)

Audiology Appointment (Ignore below questions and click submit)

Are you a contact lens wearer?

I am a contact lens wearer

I do not wear contact lenses

Please tell us your reason for this appointment (tick one): *If you have a need for urgent or emergency eye care please call us on 01844 212048, do not complete this form.

I need/want to replace my Spectacles or Contact Lenses and would like an eye exam (because my vision is impaired/because I have broken or lost my Specs or Contacts)

I need/want to replace my Spectacles but I had an eye exam recently and I am happy that my prescription is up to date.

Routine, I am not having any particular problems, but my eye exam check up is due/overdue

Special Requests

What we will do:

We will get back to you to make sure we understand your need, and to complete your booking.
We will send you an email summary of the special instructions we will need you to follow when you attend for your appointment.

Thanks for submitting!