Bausch & Lomb

Personal Particulars

Title

-- Please Choose -- Mr Mrs Miss

Name

• Surname

• Name

(As in identity card or passport)

Gender

MaleFemale

Identity Card Number

(* Example: S1234567A)

Age

-- Please Choose -- 15 years & below 16 to 24 25 to 34 35 to 44 45 to 54 55 years or above

Mobile Number

Email Address

Mailing Address

Preferred Trial Centre

-- Please Choose -- 88 PREMIER (ORCHARD ION) BEJEWELLED (ION ORCHARD) BETTERVISION (CAUSEWAY POINT) BETTERVISION (COMPASS POINT) BETTERVISION (NEX) BETTERVISION (NORTH POINT) BETTERVISION (NOVENA SQUARE) BETTERVISION (RAFFLES XCHANGE) BETTERVISION (SUN PLAZA) BETTERVISION (TAMPINES MALL) BETTERVISION (VIVOCITY) BETTERVISION (WEST MALL) BLUE EYES (AMK HUB) BLUE EYES (CITY SQUARE MALL) BLUE EYES (JURONG POINT) BLUE EYES (SQUARE 2) BLUE EYES (IMM) BLUE EYES (NEX) CAPITOL (ANCHORPOINT) CAPITOL (BRAS BASAH PLAZA) CAPITOL (CAUSEWAY POINT) CAPITOL (COMPASS POINT) CAPITOL (FORUM GALLERIA) CAPITOL (IMM) CAPITOL (JURONG POINT) CAPITOL (NORTH POINT) CAPITOL (RAFFLES CITY) CAPITOL (RIVERVALE MALL) CAPITOL (TAMPINES MALL) CAPITOL (TANGLIN MALL) CAPITOL (TIONG BAHRU PLAZA) CAPITOL (WHITE SANDS) CEYE BEJEWELLED (AMK HUB) CEYE BEJEWELLED (TAMPINES 1) IEC (VIVOCITY) INSIGHT OPTICAL (VIVOCITY) KOOLOOK (SUNTEC CITY) OPTICAL 88 (313 @ SOMERSET) OPTICAL 88 (BEDOK CENTRAL) OPTICAL 88 (BUKIT PANJANG PLAZA) OPTICAL 88 (CAUSEWAY POINT) OPTICAL 88 (CITYLINK MALL) OPTICAL 88 (CLEMENTI CENTRAL) OPTICAL 88 (IMM) OPTICAL 88 (JURONG POINT) OPTICAL 88 (LOT 1 SHOPPERS MALL) OPTICAL 88 (MARINA SQUARE) OPTICAL 88 (NORTH POINT) OPTICAL 88 (ORCHARD CENTRAL) OPTICAL 88 (PARKWAY PARADE) OPTICAL 88 (PLAZA SINGAPURA) OPTICAL 88 (REPUBLIC PLAZA) OPTICAL 88 (SUNTEC CITY) OPTICAL 88 (TAMPINES MALL) OPTICAL 88 (TOA PAYOH CENTRAL) OPTICAL 88 (WISMA ATRIA) SHINAGAWA OPTICAL (WHEELOCK PLACE) SPECIALIST EYE CARE CENTRE (GREAT WORLD CITY) SPECTACLE HUT (AMK HUB) SPECTACLE HUT (BUGIS JUNCTION) SPECTACLE HUT (BUKIT PANJANG PLAZA) SPECTACLE HUT (CENTURY SQUARE) SPECTACLE HUT (CITY SQUARE MALL) SPECTACLE HUT (CLEMENTI MALL) SPECTACLE HUT (GIANT @ VIVOCITY LEVEL 1 C2) SPECTACLE HUT (HARBOURFRONT CENTRE) SPECTACLE HUT (HOUGANG MALL) SPECTACLE HUT (IMM) SPECTACLE HUT (JUNCTION 8) SPECTACLE HUT (JURONG POINT) SPECTACLE HUT (KOVAN HEARTLAND MALL) SPECTACLE HUT (LOT 1 SHOPPERS MALL) SPECTACLE HUT (MY VILLAGE) SPECTACLE HUT (NEX) SPECTACLE HUT (NORTH POINT) SPECTACLE HUT (NOVENA SQUARE) SPECTACLE HUT (ORCHARD ROAD CENTRAL) SPECTACLE HUT (PLAZA SINGAPURA) SPECTACLE HUT (QUEENSWAY SHOPPING CENTRAL) SPECTACLE HUT (RAFFLES CITY) SPECTACLE HUT (SEMBAWANG SHOPPING CENTRE) SPECTACLE HUT (SHOPPING PODIUM OUB CENTRE) SPECTACLE HUT (SUNTEC CITY MALL) SPECTACLE HUT (TOA PAYOH CENTRAL) SPECTACLE HUT (UNITED SQUARE) SPECTACLE HUT (WEST COAST PLAZA) SPECTACLE HUT (WEST MALL) SPECTACLE HUT BOUTIQUE (MARINA BAY SANDS) SPECTACLE HUT BOUTIQUE (MARINA BAY SANDS) SPECTACLE HUT BOUTIQUE (MARINA SQUARE) SPECTACLE HUT BOUTIQUE (MARINA SQUARE)

(Click here to view our list of Trial Centres.)

Vision Questionnaire

Vision Situation

• Left Eye
• -- please select -- Myopia 近視 Hyperopia 遠視 Presbyopia 老花 Astigmatism 散光 Astigmatism 散光 and one of the above
• Degree (Myopia)
• -- please select -- 150 175 200 225 250 275 300 325 350 375 400 425 450 485 500 525 550 575 600 650 700 750 800 850 900 950 1000
• Right Eye
• -- please select -- Myopia 近視 Hyperopia 遠視 Presbyopia 老花 Astigmatism 散光 Astigmatism 散光 and one of the above
• Degree (Myopia)
• -- please select -- 150 175 200 225 250 275 300 325 350 375 400 425 450 485 500 525 550 575 600 650 700 750 800 850 900 950 1000

Current vision correction methods

Wear glasses only
Monthly disposable contact lenses
Two-week disposable contact lenses
Daily disposable contact lenses
Others

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