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 Accepted file types: jpg, gif, png. Which eye is affected?*RightLeftBothUnsureDo you have any loss of vision?*NoneMildModerateSevereDo you have any eye pain?*NoneMildModerateSevereWhen 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.
