Medical Evaluation Report
Please send below information to firstname.lastname@example.org (or email@example.com), we will contact with you soon.
1, Your name
5, How is your central vision and peripheral vision ?
6, Can you still manage your daily life independently ?
7, Do you mind telling your age and how long have you been diagnosed of RP ?
8, Do you have cataract or glaucoma ?
9, How did you first hear about Restorerpvision.com ?
10, Do you have other chronic diseases like hypertension, diabetes or heart diseases ?
11, Other information about your condition you want to share ?
12, Phone number
(If you feel that it’s easier to speak over the phone, and you are comfortable to leave your number, please do so.)
13, In order to help you more efficiently, please attach to us recent medical reports/images, such as scans.