Testing Title First Name Last Name Phone Email Age Group 19-39 40-55 56+ Preferred Location The Harley Street Eye Centre (London) Weymouth Street Hospital (London) Phoenix Hospital Chelmsford (Essex) One Hatfield Hospital (Hertfordshire) London Cataract Centre (London, Bupa Only) How will you be funding your treatment? I am insured I am self-pay If insured, please select your insurance provider: Allianz Aviva Bupa Cigna Saga Vitality WPA I am not insured Vision Concerns Farsightedness (difficulty seeing up close) Nearsightedness (difficulty seeing far away) Astigmatism (distorted vision) None of the above Glasses or Contact Lens Use Driving Computer work Reading All of the above None of the above Previous Eye Procedures LASIK PRK LASEK SMILE Cataract Surgery Lens Replacement Surgery None of the above Medical Conditions Multiple Sclerosis Lupus Dry Eyes Keratoconus Diabetic Retinopathy None of the above Overall Eye Health Excellent Good Fair Poor Are you experiencing eye pain or discomfort? Yes No Have you noticed recent changes in your vision? Yes No If Yes, please describe: Which service do you require? General Ophthalmology Cataract Surgery YAG Laser Capsulotomy Laser Eye Surgery (ages 20–45) Lens Replacement Surgery (ages 40+) ICL Surgery (ages 20–50) Eyelid Surgery Glaucoma Care Medical Retina Vitreoretinal Eye Floaters Conjunctival Naevus Removal Pterygium Removal Pinguecula Removal Other Please note any specific details: GDPR Agreement By submitting this form, I agree to be contacted by Blue Fin Vision® for a follow-up on my self-assessment. Submit
