CentraSight: Candidacy Questionnaire Form

First Name *

Middle Name

Last Name *

Address *

City *

State *

ZIP Code *

Email Address *

Email Address (confirm) *

Phone Number *

How did you hear about CentraSight?

Please specify:


Do you have macular degeneration? Yes No

If YES, do you have macular degeneration in both eyes? Yes No

Have you had laser treatment or drug injections inside your eye for macular degeneration? Yes No

If YES, was the laser treatment or drug injection inside your eye performed within the last 6 months? Yes No

Does macular degeneration affect your central vision? Yes No

If yes, does it affect your ability to read? Yes No

Do you have difficulty recognizing people due to your vision? Yes No

Does your vision allow you to drive? Yes No

Are you legally blind? Yes No Not sure

Have you had cataract surgery? Yes No

If yes, have you had cataract surgery in both eyes? Yes No Not sure

I would like to receive email and printed literature about CentraSight. Yes No

I hereby consent to VisionCare Ophthalmic Technologies, Inc. (VisionCare) contacting me to discuss any and all treatment options that I (or the person for which I am providing care and/or assistance) may have with VisionCare. I further consent and acknowledge that this contact may be through mail, electronic mail or by telephone from VisionCare, its agents and representatives including any physician, nurse or other health care professional working with or on behalf of VisionCare. I consent to VisionCare sharing with such health care professionals any and all necessary and appropriate patient healthcare information (PHI) needed for purposes of such health care professional's determination of my treatment options with VisionCare. I understand that I can withdraw this consent at any time and can notify VisionCare of such withdrawal. Yes No




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