Eye Care Assistance Request Form

First Name*

Last Name*

Address*

City*

State*

ZIP Code*

Phone

Date of Birth*

Email*

Have you ever or do you currently wear glasses?*

Yes

If Yes, When did you get your last eye exam?

Do you have a history of eye problem?*

Yes

If Yes, I had my eye problem before, Please Explain

Do you currently have health insurance?*

Yes

18years or older

-.*

Income must be at or below 200% of the federal poverty level