Clone of Eye Exam Request

Eye Exam Request

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.