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I am interested in participating in the choroideremia study.
I am a parent of someone with choroideremia, and I am completing this form for my child.
Child's Name (if applicable)
Have you been told by a doctor that you have choroideremia? Yes No
Are you 18 years of age or older (or a parent of a child at least 5 years of age or older)? Yes No
Have you previously been in a research study at the Eye Institute?
Are you currently or have you ever been a patient at the Eye Institute?
Do you currently hold a valid driver's license?
Have you had any genetic testing done for your condition?
Comments or Questions
By submitting this form, I acknowledge that I would like to be contacted about the choroideremia study and understand that submission of this form in no way obligates me to participate in this study.
We will contact you as soon as we can. Thank you for your patience.
If you have questions please contact the Advanced Ocular Imaging Program at (414) 955-2647 (AOIP).
Advanced Ocular Imaging Program
925 North 87th Street
Milwaukee, WI 53226
Phone: 414-955-AOIP (2647)