FILL UP FORM NOW!

Name:
From:
Tel/Hp:	Other:
Appointment Date:
Preferred Time:
Purpose:	Suitability Test only
	Suitability Test and LASIK treatment
Need to book hotel room?	Yes     No
Check In Date:
Check Out Date:
Preferred Hotel:	Boulevard Hotel Cititel Hotel
Preferred Room Type:	Superior  Standard   Deluxe Deluxe   Executive Superior Pinnacle   Executive Deluxe     Studio Suite     Premier Suite
Special Request:

P/S	Please layoff the contact lenses as shown in the following chart

	Soft Contact Lens	Hard Contact Lens
Suitability Check	min. 3 days	min.7 days
LASIK Treatment	min. 7 days	min. 21 days