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* 1. Contact Information

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* 2. What eye health problem(s) are you being treated for?

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* 5. If yes, what is the name of the treatment or medication?

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* 6. Were you required to try a different drug before obtaining the doctor recommended drug for your treatment?

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* 7. What was the impact for you/your health of the steps your health plan required you and the doctor to take for the treatment of your vision condition?

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* 9. What is your preferred method of contact?

Please Note:

Prevent Blindness may reach out to you about telling your story to members of a state assembly, becoming a volunteer patient spokesperson for the initiative or other opportunities to share your story to the public.

The information you have provided in this form will NOT be shared with any private entity including corporations or businesses, employers, or insurance companies. By volunteering to share your story, you will help us educate policy makers about the potential impact of Step Therapy on the eye health patient. Thank you for sharing! 

Please contact Sara Brown, Director of Government Affairs, with any questions:
sbrown@preventblindness.org
312.363.603
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