First Name (required)

Last Name (required)

Practice

Number of Doctors

Address 1

Address 2

City

State / Province

Country

Phone (required)

Email (required)

When is the best time to reach you?

Are you currently providing screening or telemedicine in your practice?

NoYes

If not, when would you like to be able to provide this valuable service to your patients?

---Immediately1-3 Months3-6 Months6-12 Months12-24 Months

Do you currently use an electronic medical record for eye examination ?

NoYes

If no : are you planning to implement the use of an electronic medical record in your practice in the next 2 years ?

NoYes

Which services are you currently or would you like to provide:

Screening for:
Diabetic Retinopathy:  Currently Provide Would like to provide
Glaucoma:  Currently Provide Would like to provide
Macular Degeneration:  Currently Provide Would like to provide

Fitering (first level reading by assistant) of patients
Diabetic Retinopathy:  Currently Provide Would like to provide
Glaucoma:  Currently Provide Would like to provide
Macular Degeneration:  Currently Provide Would like to provide

Other Services
Optimize efficiency and resources in the clinic or institution Yes No
Remote telemedicine consultation Yes No