Appointment Form Appointment Form Appointment Form Name * Name First First Last Last Age * Gender * MaleFemaleTransgenderNon-binary/Non-conformingPrefer not to respond Contact Number * Email Appointment Date: * Appointment Time: * 12:00 PM12:15 PM12:30 PM12:45 PM1:00 PM1:15 PM1:30 PM1:45 PM2:00 PM2:15 PM2:30 PM2:45 PM3:00 PM3:15 PM3:30 PM3:45 PM4:00 PM4:15 PM4:30 PM4:45 PM5:00 PM5:15 PM5:30 PM5:45 PM6:00 PM Address * Address Address Address City City State/Province State/Province Zip/Postal Zip/Postal Appointment For: * General Optometry Eye Examination Soft/RGP Contact Lens Trial OrthoK Contact Lens Trial Scleral Contact Lens Trial Lazy Eye/ Amblyopia Therapy Check all that applies: मलाई मेरो चस्मा/कन्ट्याक्ट् लेन्स परिवर्तन गर्नु छ । मलाई एकपटक कन्ट्याक्ट् लेन्स आँखामा लगाएर अनुभब गर्नु छ । मलाई नजिकको मसिनो कुरा हेर्ने कन्ट्याक्ट् लेन्सबारे बुझ्नु छ । मलाई अल्छि आँखाको उपचारबारे बुझ्न मन छ । मलाई डेढो आँखा सिधा बनाउने उपचारबारे बुझ्न मन छ । मलाई साना बालबालिकाहरुको पावर बढ्ने क्रम कसरी रोक्ने भनेर जान्न मन छ । Clinic To Visit * Choose the clinic you want to visit ▼ :Everest Eye Care (Satdobato, Lalitpur)Everest Eye Care (Imadol, Lalitpur)Lumbini Eye Care Center (Hospital Line, Butwal)Mahalaxmi Eye Hub (Lubhu, Lalitpur)Metro Eye Care (Subidhanagar, Kathmandu)Pathivara Optical & Eye Clinic (Furniture Line, Damak) Any Queries/Comments If you are human, leave this field blank. Book An Appointment Δ
