Course Registration Form
Fill out the form carefully for registration
Name
*
First Name
Middle Name
Last Name
E-mail
*
example@example.com
Mobile Number
*
Name of practice or institution
*
City
*
State
*
Role
*
Please Select
OD
MD
Student
Staff member
Other
Approximately how many new cases of keratoconus or corneal ectasia are diagnosed in your practice each year?
*
Please Select
Less than 5 cases
5-10 cases
11-20 cases
21-30 cases
More than 30 cases
Do you recommend FDA-approved corneal cross-linking for your patients with progressive keratoconus?
*
Please Select
Yes
No
Who do you refer your keratoconus patients to for corneal cross-linking?
*
What diagnostic equipment do you have available in your office and/or use to diagnose keratoconus?
*
Are you aware that there is only one FDA-approved cross-linking device and drug combination in the US?
*
Please Select
Yes
No
Submit
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