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028 9032 202089-91 Academy Street, Belfast, BT1 2LSMon - Fri 9am - 5.30pm | Thurs close at 9pm | Sat 9am - 1pm
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Cathedral Connect
Cathedral Eye Clinic
A Centre of Ophthalmic Excellence
Cathedral Eye ClinicCathedral Eye Clinic
  • Home
  • Treatments
    • Freedom From Glasses
      • VisuMax SMILE Laser
      • Lasik
      • Lasek – PRK
      • ICL Lens Implantation
    • Cataracts & Lens Surgery
      • Cataracts
      • Monofocal and Multifocal Lenses
    • Eye Health
      • Glaucoma
      • Keratoconus
    • Treatment Journey
    • Cross Border Patients
    • Rehabilitation Medicine
    • Cathedral Aesthetics
  • About Us
    • Our Team
    • Pricing
    • Articles
    • Sponsorships
    • Robotics
    • Cathedral Legal
  • Contact
Make an appointment
  • Home
  • Treatments
    • Freedom From Glasses
      • VisuMax SMILE Laser
      • Lasik
      • Lasek – PRK
      • ICL Lens Implantation
    • Cataracts & Lens Surgery
      • Cataracts
      • Monofocal and Multifocal Lenses
    • Eye Health
      • Glaucoma
      • Keratoconus
    • Treatment Journey
    • Cross Border Patients
    • Rehabilitation Medicine
    • Cathedral Aesthetics
  • About Us
    • Our Team
    • Pricing
    • Articles
    • Sponsorships
    • Robotics
    • Cathedral Legal
  • Contact

Patient Health Questionnaire

1Personal Details
2Contact Details
3Doctor and Optician Details
4Medical Questionnaire
5Consent
6Insurance
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Name(Required)
DD slash MM slash YYYY
Home Address(Required)
Do you take any regular medication?
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Accepted file types: jpg, gif, png, pdf, Max. file size: 8 MB, Max. files: 10.
    You may take a photo of your medication and upload the pictures here. Don’t worry of you can’t do this, instead just give us a few details in the previous box
    Do you take Warfarin?
    Please enter a number from 0 to 10.
    Do you have any allergies?
    Do you have any history of previous eye related conditions and or surgery?
    Eye conditions
    Do you wear glasses?
    Is there a prism in your glasses?
    Do you wear Hard or Soft Contact Lenses?
    Please select
    Do you experience glare from lights?
    Do you have an HGV driver’s license, or a pilot’s license?
    Do you have a pacemaker fitted?
    Do you play contact sports?
    Have you had any exposure to the rubella virus / a rash or anyone with a rash in the last 4 weeks?
    Are you pregnant or have you had a baby in the last 6 months?
    Consent to Share your Data(Required)
    It may be necessary communicate with your GP and your Optometrist. We therefore require your consent to communicate with him/her.
    Will you be using Health Insurance to cover the cost of your appointment?

    Treatments
    • VisuMax SMILE Laser
    • Lasik
    • Lasek – PRK
    • Cataracts
    • ICL Lens Implantation
    • Monofocal and Multifocal Lenses
    • Rehabilitation Medicine
    • Phone numbers:
      028 9032 2020 (NI)
      01 4311094 (ROI)
    • Address:
      89-91 Academy St, Belfast BT1 2LS
    • Mail:
      info@cathedraleye.com
    • Business hours:
      Monday - Friday: 9:00am - 5:30pm
      Thursday Evening: 5:00pm - 8:00pm
      Saturday: 9:00am-1:00pm
      Sunday: Closed

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