Ophthalmology/Eye Institute

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Research Volunteer Form

eyeGENE® National Ophthalmic Disease Genotyping Network

Please select an option below. Please complete all fields.

  I am interested in participating in the eyeGENE® project.

  I am interested in having my child participate in the eyeGENE® project.

  I am a family member of someone (other than a minor child) who is interested in participating in the eyeGENE® project.

Your Information

First Name


Last Name


Email Address


Area Code


Phone Number


City, State


Family member's name (if applicable)


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

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

Have you been seen by another eye doctor within the past year?

 Yes    No    Not sure

 

Additional Information

I have been told by an eye doctor that I have the following eye condition:


I have a family history of the above condition.

 Yes    No

If Yes, please explain


Comments or Questions


 

By submitting this form, I acknowledge that I would like to be contacted about the eyeGENE® project.

We will contact you as soon as we can.  Thank you for your patience.

If you have questions please contact Krissa Packard at (414) 955-7910.

 

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Page Updated 10/22/2013