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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 Date Selector
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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Our Details

20 Hall Street
Pukekohe  
   
Phone 09 238 3796
  0800 SEEING
Email pukekohe@optik.co.nz
   

 
     
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