Eye Promises Registration Form

Single Line Text

Practice Name

Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Main Contact

Business Phone

Business Email *

Website / URL

GOC Registration Number

GOC Registration Number

GOC Registration Number

VAT Reg No: (if applicable)

Section 2: Declaration

We hereby sign up to deliver the following 5 Eye Promises for all of our patients:

We put long term eye health care first
We give patients as much time in the consultancy chair as their individual needs require
We will always try to offer repeat appointments with the same practitioner
We will use state of the art imaging equipment as a way of monitoring long term eye health
We will only recommend eyewear that will benefit patients

Signed:

Name:

Position:

Date