Prevent Blindness America: Survey - Share Your Story With Us!

Share Your Story With Us!

Have you or has someone you know experienced vision loss, eye disease or a serious eye injury? By sharing your story with Prevent Blindness America, you can help spread the word about the importance of eye health and safety and help us advocate for better eye care and access to vision services for all Americans.

1.

Please provide your background information.

*

Name:

First Required	Last Required

*

Email: Required

Street 1:

Street 2:

City/State/ZIP:

City	State	ZIP

*

Phone Number: Required

Employer:

Occupation:

Gender:

Yes, I would like to receive e-mail from Prevent Blindness America

Email Format:

Yes, I would like to receive postal mail from Prevent Blindness America

*2.

Question - Required - This story is most related to (please select all that apply):

	glaucoma
	age-related macular degeneration
	diabetic eye disease
	cataract
	a workplace eye injury
	a home or sports eye injury
	amblyopia
	strabismus
	other

*3.

Question - Required - How did you (or a loved one) find out you had this disease or condition?

*4.

Question - Required - How has this eye disease or condition affected your daily life or that of your loved one?

*5.

Question - Required - Do you have insurance coverage for treating this eye disease or condition?

*6.

Question - Required - Have you had trouble paying for treatments relating to this eye disease or condition?

7.

Question - Not Required - Please add any other comments you would like to make about your experience with this eye disease or condition.

By clicking the "Share Your Story" button, you agree to these terms and conditions. Please review these terms before you submit your story. Thank you!