• Located in Wuse, Gudu and Utako
  • Wuse: +234-808-358-8730
  • Gudu: +234-810-840-6080
  • Utako:+234-818-433-9441

Form

Patient Resources

Patient Registration

Please complete the information below and submit the form online, or if you prefer print out the form after full or partial completion, and bring it when you come to our office. This form contains confidential information and is delivered to your optometrist through a secure Internet connection.

Your information will be treated as confidential.


Patient Information



Personal Information





Eye History

Please check off any current conditions you suffer from


Glasses & Contact Lens History




Medical History





Please check off any current conditions you suffer from


Additional Comments


Privacy & Consent

Your information is collected for the purpose of providing appropriate eye care and maintaining your patient record. Please review the information provided before submitting this registration form.

Important Information

Please ensure that the information supplied on this form is accurate and complete. Providing accurate medical and eye history helps our clinical team make informed decisions regarding your care.

If you are experiencing sudden vision loss, severe eye pain, serious eye injury, or another urgent eye problem, please contact our clinic directly rather than relying solely on this online registration form.

Your information is submitted securely and will be handled confidentially by De-Lens Ophthalmics.

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