Please use this form to provide information regarding your current ocular concern.Name* First Last What eye concern are you having? Please be specific.*Please upload pictures of the affected eye(s) if it is visible in a photo. (optional) Drop files here or Select files Accepted file types: jpg, gif, png, Max. file size: 31 MB, Max. files: 6. Which eye is affected?* Right Left Both Unsure Do you have any loss of vision?* None Mild Moderate Severe Do you have any eye pain?* None Mild Moderate Severe When did your symptom(s) begin?(optional)How often do you experience your symptom(s)?(optional)Does anything help relieve your symptom(s)? (for example, eye drops, closing eye, Tylenol, etc)(optional)PhoneThis field is for validation purposes and should be left unchanged.
