Ophthalmology/Eye Institute

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Research Volunteer Form

Advanced Ocular Imaging: Glaucoma

Please select an option below. Please complete all fields.

I am interested in participating in the glaucoma study.

I am a parent of someone with glaucoma, 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 glaucoma?

 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 glaucoma 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).

 

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Page Updated 10/22/2013