Eye Exam Request
Please complete the following information and someone will call you soon to discuss your request. Thank you.
Your date of birth
What language are you most comfortable speaking?
Please enter a valid phone number.
Address (if you do not have an address, type in "Homeless.")
Street Address Line 2
State / Province
Postal / Zip Code
Do you have vision insurance?
How many people live in your household?
1 (just you)
8 or more
What is your households income each year (this cannot be blank, if you have no income type in 0)?
If you are given a voucher, do you agree with the following?
I understand that the eye exam vouchers have an expiration date and I will call and make an appointment as soon as possible.
I understand that I will bring the voucher with me to my eye appointment to pay for my eye exam.
I understand that the voucher is for me and cannot be transferred to another person.
I understand that if the voucher is lost or expires it will not be replaced.
I understand that if I make an appointment and miss it, another voucher will not be given.
I understand that I may request a voucher every two years.
My signature confirms that all my responses are true.
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