Preview mode
Published
Copy responder link
Request edit access
Patient Reporting Form
Kindly complete this form for each surgery performed under the Visual Freedom Foundation program.
Practice Name *
Please provide your name below *
Point of contact if different from you *
What is the date of the surgery you performed? *
MM
/
DD
/
YYYY
Please provide a patient identifier (patient initials) *
What is the patient's age and gender? *
What is the patient's disability? Please describe in 3 sentences, example: 53 year old, high myope, with no arms *
Please indicate below which procedure was performed on the patient *
Required
Please use this link to upload any photos, videos (pre-surgery, post surgery, team photos). Be sure to include your name/practice name in the name of the file: 
https://drive.google.com/drive/folders/114aafz4e6ymfs6mT1jpJ74_yi8kogisQ?usp=share_link
Thank you for generously donating your time and expertise to perform this procedure as part of the Visual Freedom Foundation. Your commitment is changing lives and expanding access to sight-restoring care.
for questions or comments please email: contact@visualfreedomfoundation.org
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of COR Communications.

Does this form look suspicious? Report

Google Forms