Participant Release for Anterior and Retinal Photos: Myelinn Data Systems Research

Thank you for your participation in our goal to better vision care and to better non-invasive diagnostic tools around the world!
This is a release form indicating that you would like to participate in our global vision therapy project (Visiontheraputix). We are collecting retinal and anterior segment photos for research purpose ONLY. We will not share any of this information without your consent and willingness.
Our objective in collecting and using these photos is to look for patterns of health and diseases using our algorithms. All information will be anomalized for security and privacy. We will use the photos provided against a broader database of photos for detection of chronic diseases and vision issues. The intent of this study is to deliver better care to rural and developing areas of the world where healthcare and vision care are limited.
Again, we thank you in advance for your willingness to participate in this global effort to improve sight for all.

Why Retina Photos are Important.

Please check this box to agree to your willing to participate to this study. We will not share any of your information without your consent. *

I agree to participating

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What is your age *

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15 -20

21 -30

31-40

41-50

51-60

61-70

71-80

81-90

What is your ethnicity *

Asian including Southeast Asia

African American

White or of European Descent

Middle Eastern

Native American

Hispanic or Latino

Other

What is your gender? *

Male

Female

Other:

Please provide your contact information if you would like for us to send a copy of your photos back to you for your records. All information will be kept confidential.

Your Name *

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Phone

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