Eye Exam Request
Please complete the following information and someone will call you soon to discuss your request. Thank you.
Name
*
First Name
Last Name
Your date of birth
*
-
Month
-
Day
Year
Date
What language are you most comfortable speaking?
Phone Number
*
Please enter a valid phone number.
Address (if you do not have an address, type in "Homeless.")
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Do you have vision insurance?
*
Yes
No
How many people live in your household?
*
1 (just you)
2
3
4
5
6
7
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?
Yes
No
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.
Clear
Submit
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