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If you would like a Gimbel Eye Centre representative to contact you to book an assessment or schedule tentative plans for surgery, please complete and submit this form.

Which Gimbel Eye Centre location would you prefer to contact you?

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First Name
 Last Name
Address
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Contact me at Home Work

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If you know your most recent prescription, please provide appropriate information below.

  SPH CYL AXIS
O.D.
Right Eye
O.S.
Left Eye

Example: -3.00 -1.50 x 150

Has your prescription been generally stable for the last year?

If you are a contact lens wearer, what type do you wear?

As far as you know, are your eyes healthy and free from previous eye injury or apparent disease?

If no, please specify

Have you had previous eye surgery?

If Yes, please specify

List any known health problems

Are you on any medication?

If Yes, please specify

Do you have any allergies to medication?

If Yes, please specify

Are you Pregnant / Nursing?

Are you a Pilot?

Who is your ophthalmologist?

Who is your optometrist?

Please enter any questions you may have here:

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