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Register with Optik
This form is for clients who would like to register with the Pukekohe practice.
Title
Given name*
Last name*
Known as
Date of birth*
Phone - home*
Phone - work
Mobile
Address
Suburb
Postcode
Email*
Occupation
GP
GP clinic
Who was your previous optometrist?
Are you interested in wearing contact lenses?
Yes
No
If you have already booked an appointment, please enter the date
Comments / message / special instructions
How did you hear about us?
Recommended by family / friend
Referred by GP
Referred by specialist
Newspaper article / advertising
Workplace contract
Online
Street appeal
I am happy to receive email newsletters from Optik Pukekohe
Yes
I give permission for Optik Eyecare to contact optometrists, eye specialists and/or my general practioner for information regarding my eye health.
I understand that all examination fees are to be paid on the day, and a deposit of 50% is required when ordering new glasses and lenses.
I have read and agree to the above conditions*
Yes
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