Salutation
Mr :  Mrs:  Miss : 

First name (required)

Last Name (required)

Date of birth (DD/MM/YYYY format) (required)

Postal Address (required)

Postal Code (required)

City (required)

Phone (required)

Mobile

Email

 Phone
 Mobile
 Email
 Through

Mr ou Mrs

Phone

Email

 Vision impaired person
 Blind
 Sighted person

 AMD
 Dry AMD
 Wet AMD
 Stargardt disease
 Retinitis pigmentosa
 Glaucoma
 Diabetic retinopathy
 Optic neuropathy
 Other
Specify if possible

Right eye

Left eye

 Yes
 No
Specify if possible

 No
 Light or moderated deafness
 Deafness

If so, do you wear a hearing aid?
 Yes
 No

 Alone
 With a white stick
 With a guide dog
 With a guide

 Your ophtalmologist
Specify (name and et contact details) :

 Your orthoptist
Specify (name and et contact details) :

 Your optician
Specify (name and et contact details) :

 Relatives

 Internet

 Press

 Other
Specify:

Is it possible for you to come to the Institute of the Vision (Paris 12th district) to participate in a test ?
 Yes
 No

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