HOME
|
SERVICES
|
ONLINE INQUIRY & APPOINTMENTS
|
EYE MDs
|
AES HOME
|
TESTIMONIALS
|
NEWS
|
CONTACT US
Please fill up this form completely as possible. All fields with
*
are required.
Email:
*
please make sure you supply a valid email address.
this will serve as your primary account identity and will also be used for retrieving
lost passwords
.
Password:
*
Verify Password:
*
First name:
Middle name:
Last name:
*
*
*
Date of birth:
January
February
March
April
May
June
July
August
September
October
November
December
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
1919
1918
1917
1916
1915
1914
1913
1912
1911
1910
1909
1908
1907
1906
1905
1904
1903
1902
1901
Gender:
Male
Female
CONTACT NUMBERS:
Phone:
country
code
area
code
phone
+
Fax:
country
code
area
code
phone
+
Mobile/Cell:
country
code
area
code
phone
+
Is your mobile phone capable of receiving SMS messages?
Yes
No
ADDRESS:
Street 1:
Street 2:
City:
Caloocan
Makati
Mandaluyong
Manila
Pampanga
Pasig City
Quezon City
Zip:
AEC QUESTIONAIRE:
Who referred you to the American Eye Center?
Physician
Former Patient
Optometrist
Company
Optical Store
Thru Internet
Other
Eye Problem?
Blurring of Vision
Cataract
Redness
Eye pain
Mass lesion
Refractive (LASIK) Surgery
Headache / Dizziness
Tearing / Discharge
Diplopia
Itching / Swelling
Floaters / Light Flashes
Glare / Haloes
Visual Field Defect
Others
Refractive History?
Glasses
Contact Lenses
Soft Contact Lenses
Hard Contact Lenses
Rigid Gas Permeable Lenses
How long?
Are you seeing and Opthalmologist in your area?
Yes
No
Friday the 21th of November, 2008
©2008 American Eye Center. All rights reserved.