Low Vision Calgary Clinic -
Macumira for Dry Aged Related Macula Degeneration
Referral Form for MacuMira
MacuMira offers a groundbreaking solution, providing the first meaningful option to address vision loss associated with Dry AMD. Administered in eye-care clinics, this treatment is easy, safe, and effective, delivering immediate visual improvements.
FREE Phone Consultation with Low Vision Optometrist-Optometrist
Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Have you been to Rockyview Hospital Sight Enhancement Clinic?
Yes
No
If Yes, Date attended Rockyview Hospital Sight Enhancement Clinic ?
Have you been to CNIB Calgary?
Yes
No
Have you been to Vision Loss Rehabilitation Calgary?
Yes
No
Do you have Dry Age Related Macular Degeneration?
Yes
No
Have you ever had any injections into your eye?
No
Do you have a pacemaker?
Yes
No
Name of Ophthalmologist (Eye Surgeon) you have seen previously? (if know)
Any Comments
Any Documents or Previous exams you wanted to share with us before the appointment
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