Registration

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Registration

Elmiron Qualifying Criteria

  • AMD (age-related macular degeneration)
  • Macular degeneration
  • Maculopathy
  • Blurry or dim vision
  • Trouble seeing at night
  • Trouble recognizing faces
  • Floaters or spots in Victim’s field of view
  • Other

If diagnosed with more than one of the eye problems listed above, please denote:

Registration

Elmiron Intake Questionnaire

IF THE INJURED PARTY IS DIFFERENT THAN THE CALLER, please provide:

EMERGENCY CONTACT – Name and address of someone that will always know how to reach you:

Registration

Elmiron/Pentosan Usage Information

Registration

SINCE TAKING ELMIRON, have you been diagnosed with any of the following (select all that apply):

Registration

Elmiron Intake Questionnaire

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