Welcome to My Survey

Hi There! Thank you so much for clicking into this survey. The information we receive from patients like you is ESSENTIAL to our ability to work with leading edge doctors and researchers to find a cure. As you know, very little is known about AZOOR because it's such a rare disease. So by providing your statistical diagnosis data you are helping to provide important metrics that can help us understand more about the disease. Please know that your information is ONLY used for the purposes of research specifically related to AZOOR.

Thank you again for providing your response to this very important survey,
Liz Upchurch
The AZOOR Society

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* 1. Contact Information 

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* 2. What is your age?

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* 3. Are you male or female?

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* 4. On which continent were you born?

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* 5. What is your ethnicity? (Please select all that apply.)

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* 6. When were you first diagnosed with AZOOR?

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* 7. Which hospital diagnosed you with AZOOR?

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* 8. Who is the doctor that initially diagnosed you?

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* 9. Do you have AZOOR in one eye or both? 

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* 10. May we contact you in the future for possible AZOOR research related purposes?

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