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The Outside Clinic Home Eye Tests in association with Lloydspharmacy

Please enter your details into the form below to request an appointment. Once the form is submitted using the 'Submit' button, we will call you back to confirm if your appointment has been accepted.

Name

Title

Forename

Surname

Address
Postcode
Telephone No.
Date of Birth

format dd/mm/yy
 
Carer/Relative's details (if to be contacted on patient's behalf)
Name

Title

Forename Surname

Address
Postcode
Telephone No.
 
Patient details
Date of last
eye test


Conditions
Medication

If you ticked yes to Diabetes is it controlled by:

If you ticked yes to Glaucoma, do you take drops:

If you didn't tick yes to Glaucoma, has anyone in your family suffered from it:
Living Accommodation

Benefits

Are you on income support? 
Funding

Do you receive Pension Credit Guaranteed?
Nature of Disabilities/
Illnesses

Do you consider yourself to have any of the following, to entitle you to a free NHS sight test at home?
When is the best time to call you?

 When would be the most convenient time to call you:

Please select a day (Please tick as many days as you like):

Please select a time of day to call (Please tick both if you are available all day)
How did you find us?

Please tell us how you found out about us. Select from the list, or enter the details into the box below:
 

 

 

 

Call usEmail usRequest Info packAre you eligibleBook a test online
Call usEmail usRequest Info packYour entitlementBook a test online