Note: If you are making this appointment on behalf of someone else, please fill in their details and use the "Other Comments" box at the bottom of the form for your own contact details if you'd like us to correspond with you.

Title

Mr Mrs Miss Ms Dr Rev Other If other, please specify:

Your firstname or initial

Your surname

Your address

Town/City

Your postcode

Your Telephone

Your email address

Have you been to Broom Reid & Harris before?

Where would you like your appointment?

Exeter Hearing Centre Torquay Hearing Centre Walker's Opticians, Sidmouth Bills Opticians, Newton Abbot Home Visit I don't mind

Who would you prefer to see (subject to availability)?

I don't mind Mr Roger H. Evans Mr Geoffrey Curtis The person I normally see

What is your appointment about?

What time and day(s) are best for you (subject to availability)?

Please use this area to provide us with any further information we may find helpful. For example:

• Problems you're experiencing
• Reason for your appointment (if you chose "Other" from the drop down menu)
• Your contact details - if you're making this appointment on someone else's behalf
• Best times for us to contact you
• If your appointment is urgent