First Name

Last Name

Email

We request your address as we send the Welcome Pack in the post and then other packs will arrive by your selected method.

Street

City

State

Postal Code

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?

Would you like to receive phone check-ins?

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

Please provide a phone number for 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