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.
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?
Are you 18 years of age or older (or a parent of a child at least 5 years of age or older)?
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?
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?
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).