You have AMD or an eye disease.

Thanks to the AMD Challenge and donations from people, The AMD Foundation is proud to improve your daily life by offering you free * a pair of 400% UV and polarized sunglasses to protect your eyes from the sun's rays as well too much ambient light.*

*Delivery fees of $ 12.95 are required

These glasses can be worn alone or over your vision glasses.

Fill in the form below and to receive your pair of glasses.

Prefix

Name and surmane

Civic number and street

Town, province, postal code

Telephone

(###)

###

####

Information collected on AMD is for AMD Foundation statistics will never be distributed

Do you have dry or wet AMD?

I was diagnosed with AMD ...

If not what eye disease do you have?

Do you receive injections?

Do you have injections in 2 eyes

The frequency of your injection

Do you know the name of the injection drug

I take vitamin supplements for the eyes

Do you have dry eyes

Message

*Available only in Canada and a pair by name and mailing address

* The Foundation reserves the right to refuse a request

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