Eye Exam Application
Eye Exam Request - Application
Your date of birth
What Language are you most comfortable speaking?
If none, please put firstname.lastname@example.org
Address (if you do not have an address, Please put in an alternate address of a friend or relative. If you do not have a mailing address, please plan to pick up your voucher at Clinic With A Heart.)
Street Address Line 2
State / Province
Postal / Zip Code
Do you have vision insurance?
Have you had a Vision Voucher with CWH within the last two years?
How many people live in your household?
1 (just you)
8 or more
What is your household's 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 receive a vision voucher every two years.
My signature confirms that all my responses are true.
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