Research Volunteer Form

Advanced Ocular Imaging: Stargardt Disease

Please select an option below. Please complete all fields.

 I am interested in participating in the Stargardt disease study.

 I am a parent of someone with Stargardt disease, and I am completing this form for my child.

Your Information

First Name

Last Name

Email Address

Area Code

Phone Number

City, State

Child's Name (if applicable)

Please answer Yes or No to the following questions. (You refers to you or your child as appropriate.)

Have you been told by a doctor that you have Stargardt disease?
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?

Yes   No   Not sure

Are you currently or have you ever been a patient at the Eye Institute?

Yes   No   Not sure

Do you currently hold a valid driver's license?

Yes   No   N/A (under 18)

Have you had any genetic testing done for your condition?

Yes   No
Additional Information

Comments or Questions


 

By submitting this form, I acknowledge that I would like to be contacted about the Stargardt disease 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
Eye Institute
925 North 87th Street
Milwaukee, WI 53226
Phone: 414-955-AOIP (2647)
Fax: 414-955-6690
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