Application Form

Welcome to Prouse & Co. We offer comprehensive eye care through our exclusive membership program. For £11 per month, our members receive an advanced eye test with state-of-the-art technology every year, and additional tailored follow-up tests whenever required. This membership ensures that our clients receive ongoing, high-quality eye care, bespoke to their individual needs.

If you are already a paid member you can book your appointment by clicking here.

Otherwise, please complete the application form below to apply for membership. We will review your application and contact you with the next steps.

Name

First Name

Last Name

Phone

(###)

###

####

Date of Birth

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

When was your last eye test?

Do you wear glasses or contact lenses?

Are you experiencing any current issues with your vision?

Are you aware that our eye tests include advanced procedures like the Optomap and OCT scans?

How do you plan to use your membership? (Select all that apply)

Regular eye check-ups

Access to emergency eye tests when needed

Discounts on glasses and lenses

Preventive eye care and health monitoring

Are you comfortable with the £11 per month membership fee and committed to maintaining this membership long-term?

What is your primary reason for choosing to have an eye test at Prouse & Co?

Please describe any specific concerns or goals you have regarding your eye health.

How did you hear about us?

If you were recommended to us, please state the person's name below:

Agreement Statement

By submitting this application, I confirm that the information provided is accurate. I acknowledge that this application does not guarantee membership approval, and that my application will be reviewed before acceptance.

Application Form

Contact us.

Prouse & Co. Locations

Application Form

Contact us.

Skelton Branch

Loftus Branch

Prouse & Co. Locations