Because Every Letter Counts Contact your trusted Eye care Practitioner to confirm your eligibility. Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.How Old Are You?Under 5050-6465-7575-8585+Has your Optometrist or Ophthalmologist diagnosed you with AMD or a form of central vision loss from a retina disease?YesNoIs your vision 20/60 or worse?YesNoDo you have untreated Cataracts?YesNo contact have What What number should we use to contact you? *What email should we use to contact you? *Submit
