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Name*
First Last
Email (will remain private)*
Enter Email Confirm Email
Year of birth
Current City, State, and Country
City State / Province / Region Country
Diagnosis
- Dry (Atrophic) Age-related Macular Degeneration
- Geographic Atrophy (Advanced Dry AMD)
- Wet (Neovascular) Age-related Macular Degeneration
- Myopic Degeneration
- Stargardt Disease
- Other
Eye/s Affected
- Left only
- Right only
- Both
Age when diagnosed
Acuity in better eye
Treatment (eye medications, supplements, etc.)
Prognosis or current state of vision
Family history of vision
Impact on my life
Past or present employment
More about me (hobbies, interests, etc.)

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