Name
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Email
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Phone
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Are You Looking To Preserve Or Recover Your Vision
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Yes
No
Which Eye Condition Are you Suffering From?
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AMD (wet or dry type)
Diabetic Retinopathy
Dry Eye
Eye Stroke (occlusion)
Glaucoma
Optic Nerve Issues (NAION, AION, optic nerve atrophy)
Retina Detachment
Retinis Pigmentosa
RP/Usher Syndrome
Stargardt's
Uveitis
Other
List Your Other Condition
Have You Filled an Application With Us In the Past, or Are You Currently A Patient?
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Yes
No
How Do You Prefer Treatment?
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In Office (Most effective)
At Home
I don't want Treatment
Are You Able To Travel To Our Clinic In New Jersey USA?
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Yes
No
Cost For In Clinic Treatment is $6,000 for 2 weeks, is this Manageable?
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Yes
No
Would You Like To Talk to Our Patient Care Coordinator About Your Treatment Options?
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Yes
No
Would You Prefer To Schedule a Call?
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Yes
No, I Would Like To Call Now
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