AM I A CANDIDATE FOR SING IMT?
Name
First Name
Last Name
Date of Birth (dd/mm/yyyy)
Address
*
Street Address
Street Address Line 2
City
District
Postal / Zip Code
Phone Number
*
Email
*
example@example.com
Have you been diagnosed with Age Related Macular Degeneration in Both eyes?
YES
NO
Are you on active treatment in any of the two eyes?
YES
NO
Did you receive any intravitreal injection in the past 6 months?
YES
NO
What is your visual accuity for your Left Eye?
Have you had cataract surgery?
YES
NO
What is your visual accuity for your Right Eye?
Are you in treatment for glaucoma?
YES
NO
Do you present any other eye condition and if yes, which one?
Do you find it difficult to read text, recognize faces or watch TV?
YES
NO
Submit
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