AMD Toolkit Request

AMD Toolkit Request form

We’re happy to be able to provide you with this comprehensive packet of information, tools and resources.

You’ll learn about AMD, how to test your vision and how to reduce lifestyle risk factors. The Toolkit includes a magnetic Amsler Grid and a Vision Simulation Card.

^Title

^First

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^Last

*Name:

*Email:

*Street 1:

Street 2:

*City/State:

*Country:

Phone:

*Zip:

Please enter your professional suffix:

* = required information

I have Dry AMD

I have Wet AMD

I know someone with AMD

I am a health care professional

I have both Dry & Wet AMD

Your request has been successfully submitted!

mailbox2 We process requests daily, but depending on where you live, it could take up to 10 days to receive your AMD toolkit. If you don’t receive it in that time, please let us know.

If you have any questions,
please call us at (310) 623-4466.

Now You Can Help

To be able to satisfy the thousands of requests we receive each year, it takes a dedicated staff and sufficient funding. We need your help meeting the growing demand for the AMD toolkits we provide free of charge. Now you can help.

You can choose to help defray our publication and shipping costs with a modest donation using:

Your generous help is appreciated!

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Please tell us about yourself:

	I have Dry AMD
	I have Wet AMD
	I have both Wet & Dry AMD
	I know someone w/AMD
	I am a health care professional
	I am a physician
	I am a student
	I am just curious