Thank you for completing the Eye Connect Quiz!

Based on your responses you appear eligible to join Eye Connect.

Please complete the following details to register for Eye Connect and begin receiving support.

First Name

Last Name

What is your AMD diagnosis? (if applicable)

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

Is your diabetes type 1 or type 2?

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?

Please provide your address details so we know where to send your information packs.

Street

City

State

Postal Code

Would you like to receive phone calls or SMS check-ins?

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

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

Please provide a mobile number for phone or SMS check-ins