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Eye Exam Application
Eye Exam Request - Application
Name
*
First Name
Last Name
Your date of birth
*
-
Month
-
Day
Year
Date
What Language are you most comfortable speaking?
*
English
Spanish
French
Arabic
Other
Phone Number
*
-
Area Code
Phone Number
Email
Address (if you do not have an address, Please put in an alternate address of a friend or relative or please plan to pick up your voucher at Clinic With A Heart.)
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Do you have vision insurance?
*
Yes
No
Have you had a Vision Voucher with CWH within the last two years?
*
Yes
No
How many people live in your household?
*
1 (just you)
2
3
4
5
6 or more
What is your family's combined yearly household income?
If you are given a voucher, do you agree with the following?
*
Rows
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 receive a vision voucher every two years.
Patient or parent/guardian of patient signature
First Name
Last Name
Submit
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