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Profile Form

Welcome to our MDList Community

Thank you for joining us! Please fill in the information below, and select “Submit” at the bottom of the form. Your profile will appear soon on our MD Community page.

Check one:*
- New profile
- Update my profile
- Remove my profile
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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MD Support • 3600 Blue Ridge Blvd • Grandview, MO 64030
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