AlSharq Healthcare

العربية

Your preferred branch

Full Name

Valid UAE Mobile Number

Nationality

Year of Birth

Do you have blurred or cloudy vision?

Yes

No

Do you have trouble seeing at night?

Yes

No

Do lights feel too bright or cause glare?

Yes

No

Do you see rings or halos around lights?

Yes

No

Do you need to change your glasses frequently?

Yes

No

Do you have diabetes or high blood pressure?

Yes

No

Have you ever had an eye injury or surgery?

Yes

No

Your Current Location

Do you have Medical Insurance?