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PRECIOUS EYES OPTOMETRIST
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Intake form
Help us serve you better
Name
*
Email address
*
Phone number
Preferred appointment date
Select
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Preferred appointment time
Select
9:00 AM
10:00 AM
11:00 AM
12:00 PM
1:00 PM
2:00 PM
3:00 PM
4:00 PM
5:00 PM
Type of eye care needed
Please select at least one option.
Full Eye Test
Eye Screening
Contact Lens Fitting
Sunglasses Consultation
Frame Selection
Do you have medical aid?
Select
Yes
No
Medical aid provider
Additional questions or comments
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