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Keratoconus Australia has been created to help control and prevent keratoconus and its effects within the Australian community. You can support our work by registering with the association. By filling in the registration form below, you will enable us to
  • keep in contact with you
  • to provide you with information on the latest research and developments in the treatment of keratoconus
  • to inform you of the association's upcoming events
  • expand our Australian database of people with keratoconus to assist research into keratoconus and advocacy initiatives on behalf of people with keratoconus.

You can register as either a Member or Supporter of Keratoconus Australia Inc.

Full membership is FREE and entitles you to a membership kit of useful information about keratoconus and the Association.

We believe Keratoconus Australia should be controlled by people with keratoconus and their immediate family to ensure our interests remain the focus of the Association's activities. Only Members have voting rights in the Association. To become a Member, you must either have keratoconus or be the parent or legal guardian of a child under the age of 18 years with keratoconus.

Supporters of Keratoconus Australia will receive periodic updates on our work and invitations to participate in the Association's activities.

Anybody can contact Keratoconus Australia Inc for more information about keratoconus, the Association's activities or assistance.

You can apply for membership of Keratoconus Australia only by completing the membership form below and agreeing to abide the Association's rules.

Required contact information is marked with an asterisk (*); other information is optional. All information is strictly confidential and subject to the Association's privacy policy. The form is also available for download in pdf format

By supplying personal and health information on this form, you agree to the collection of that information by the Association and its volunteers.

 
Membership form (required for enrolment as a Member)
  First Name*
  Last Name*
  Street Address *
  Suburb/Town*
  State*
  Postcode*
  Country*
 


*
I wish to become a Member Supporter of
Keratoconus Australia Inc (Association).

 
*
If applying for member status, I certify that either
I have keratoconus
I am the parent or legal guardian of a minor with keratoconus. My relationship is

(e.g. parent or legal guardian - specify please)
 


*In the event of my admission as a Member, I agree to be bound by the rules of the Association.

I agree I disagree

 


*Date of birth(for security)

 

Home Phone

  Work Phone
  Mobile Phone
  Please check button if you DO NOT want to receive occasional information bulletins about Keratoconus Australia
  *Email address
 
*
Can we send information by email?
Yes No
  Your profession
  Will you assist Keratoconus Australia Inc.
Yes No
   
  Keratoconus details (optional and subject to privacy policy)
  Do you have keratoconus?
Yes No
 

If "Yes," year first diagnosed

 

  Do you rub your eyes vigorously or have you done so in the past?


 

Have you had corneal crosslinking (CXL)


  If "Yes," year of most recent CXL

 

Which eye had crosslinking?


 

 

Have you had a corneal graft?
Yes
No

  If "Yes," year of most recent graft

  Which eye is grafted?




  Name of ophthalmologist
  Ophthalmologist suburb
  Do you wear
Glasses Contact lenses Both
  Name of optometrist
  Optometrist suburb
 
Private Health Fund
 

 

 
Like much information transmitted by email and internet, the information you submit here is not encrypted and may be capable of interception by third parties.