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* 1. In what year were you born? (enter 4-digit birth year; for example, 1945)

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* 2. What is your postal code? (enter a valid postal code; for example, A1A 2B2)

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* 3. In what year, approximately, were you diagnosed with glaucoma? (enter a 4-digit year; for example, 1945)

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* 4. Has your glaucoma been diagnosed in one or both eyes?

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* 5. Would you be interested in providing your name and contact information so that we can follow-up with you? This would not be shared in any way, and would only be used to facilitate future communications between you and a representative from the Foundation Fighting Blindness. 

If you do not want to be contacted, just ignore these fields and click "next" at the bottom of the page.

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