Book an Appointment First Name* Last Name* Gender*MaleFemale Date of birth* Email* Phone (including area code)* Best time to call*Best time to call*AnytimeMorning (9am - 12pm)Lunch (12pm - 2pm)Afternoon (2pm - 6pm) Preferred clinic*Select preferred clinic*HornsbySydney City Address Line 1Address Line 2 City State / Province / Region Postal / Zip Code Country*Select the country*Australia Do you see well with your glasses or contact lenses?*YesNoNot sure Do you have any problems with your eyes apart from needing glasses or contact lenses?*NoNot sureYes (please describe briefly) Physical Activities/Sports Will you need help financing your procedure if you are deemed suitable?*YesNoNot sure If deemed suitable for the procedure, when are you likely to want to book?*Immediately1-3 months3-6 months6-9 months9-12 monthsDon't know/Not sureHow did you find out about us?How did you find us?*FacebookGoogleOther Search EngineFamily / Friend / Perfect Vision PatientOptometristGPPerfect Vision Staff / AssociateEventFacial Rejuvenation ClinicNot Sure / Prefer Not To Answer Questions/CommentsI have read and understood the privacy policy.
