FREE EYEGLASSES

Free Prescription Eyeglasses
Patient Name*

First NameLast Name
Patient Birth Date*

MonthDayYear
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Patient E-Mail
example@example.com
Annual Income*
Reason for needing free eyeglasses:*

Cannot afford copayUninsured/UnderinsuredOther
Please list the names and color (i.e. Eye Care For Detroit Daisy - black) of your preferred pairs of eyeglasses (up to 3). (https://www.eyeglasses.com/brands/eye-care-for-detroit)*
Submit your eyeglass prescription

(Prescription must not be older than one calendar year - please make sure your prescription has a PD (pupillary distance) value on it.)
File Upload*

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Free Prescription Eyeglasses