Last eye examination date, please state approximate date if unsure e.g december 2016 or 2 years ago

Name

Date of birth

Address

Phone

Email Address

Eligibility criteria Eligibility criteria Aged 60 or over Aged under 16 Aged 16,17 or 18 and in full time education Registered blind or partially sighted Diagnosed with diabetes or glaucoma Considered to be at risk of glaucoma, as advised by an optician Aged 40 or over and your mother, father, brother, sister, son or daughter has been diagnosed with glaucoma Receiving benefits (Income Support, Income-based Jobseeker’s Allowance, Income-related Employment and Support Allowance or Pension Credit Guarantee Credit) Entitled to, or named on, a valid NHS tax credit exemption certificate On a low income and named on a valid HC2 (full help) or HC3 (partial help) certificate Eligible for an NHS Complex Lens Voucher (our optician will advise on the entitlement

Additional information i.e. type of physical/mental health illness or special instructions