First Name

Last Name

Email

We request your address and phone number as we conduct an initial Welcome Call and also send a Welcome Pack in the post (subsequent packs will be delivered via your selected method below).

Street

City

State

Postal Code

Phone Number

Are you living with Age-related Macular Degeneration?

What is your Age-related Macular Degeneration diagnosis?

Are you living with Diabetes?

Is your diabetes type 1 or type 2?

What is your Diabetes related Eye Condition diagnosis? (if applicable)

You must be living with Age-related Macular Degeneration or an eye condition related to diabetes to be able to join Eye Connect - please update your selection above ^

How is your vision?

Are you receiving treatment for your eye condition/s? (e.g. injections, laser, virectomy)

How would you like to receive the information packs provided as part of Eye Connect?

The Eye Connect service offers regular check-in phone calls with our trained and friendly helpline team, allowing you to ask general questions or seek further information between your visits to your eye health professional.

Would you like to receive phone check-ins?

How often would you like to receive phone check-ins?

By submitting your personal details to Macular Disease Foundation Australia (MDFA), you consent to MDFA using your information to deliver our services, communicate with you, and improve our support offerings. Your security is important to us, so we take reasonable steps to make sure your personal information is accurate, secure, and handled transparently.

You can find out more by reading our Privacy Policy