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Form Test

SMILE Self-Test

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First Name(Required)

Last Name(Required)

Phone(Required)

Email(Required)

What is your age?

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Without my glasses and contacts… (Check All That Apply)(Required)

Farsightedness : I have trouble reading and seeing things up close‎

Nearsightedness : I have trouble driving and seeing things far away‎

Astigmatism : I have distorted vision and cannot see very well‎

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What do you usually wear? (Check All That Apply)(Required)

Glasses‎

Contacts‎

Reading Glasses‎

None of Them‎

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Do you have any of the following? (Check All That Apply)(Required)

Rheumatoid Arthritis‎

Multiple Sclerosis‎

Lupus‎

Cataracts‎

Keratoconus‎

Diabetic Retinopathy

Prior Eye Surgery‎

Prior serious eye injury‎

Are you pregnant or nursing?‎

None of the above‎

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I would like to see well at a distance without relying on glasses and contact lenses.(Required)

Rate this statement on a scale of 1 to 5 with 1 being the lowest.

NW Eyes glasses and contact lenses test

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5

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I would like to see well up close without relying on glasses and contact lenses.(Required)

Rate this statement on a scale of 1 to 5 with 1 being the lowest.

1

2

3

4

5

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Would your lifestyle improve if you were to become less dependent on glasses and contact lenses?(Required)

Would your lifestyle improve if you were to become less dependent on glasses and contact lenses?

Yes

No

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Our Specialties

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Retina & Vitreous

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our locations

Seattle - Northgate

332 NE Northgate Way
Seattle WA 98125

tel. 206.528.6000 fax. 206.528.0014

Sequim

795 N. 5th Ave.
Sequim, WA 98382

tel. 360.683.2010 fax. 360.683.2320

Smokey Point

16404 Smokey Point Blvd.
Suite 303
Arlington, WA 98223

tel. 360.658.6224 fax. 360.658.6227

Renton

1412 S.W. 43rd St. Suite 310
Renton, WA 98057

tel. 425.235.1200 fax. 425.917.9465

Mount Vernon

1306 Roosevelt Ave.
Mount Vernon, WA 98273

tel. 360.428.2020 fax. 360.428.6918

Whatcom Eye Surgeons Bellingham

2075 Barkley Blvd.
Suite 205
Bellingham, WA 98226

tel. 360.676.6233 fax. 360.676.6298

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If you are currently experiencing eye problems, please contact our office at 206-528-6000 or 800-826-4631 for an appointment.

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