Free Eye Exam & Glasses
Complete this form and you will be contacted to set up an appointment to see the Eye Doctor for free and receive glasses for free if recommended. If you have any questions please call 770-973-0014 or email firstname.lastname@example.org. This service is brought to you courtesy of VSP Eyes of Hope Program, the We CARE Veterans Fair and United Military Care.
Please enter a valid phone number.
Select Branch of Service
Choose branch of service for Veteran.
List the person or persons who need an appointment along with their age:
Example: John, 57, Mary 52, Billy 20
To qualify for no cost exam and eyeglasses you must meet the income requirements listed above. Please check the appropriate box.
I meet the income requirements listed above
I do not meet the income requirements listed above
I'm not sure if I meet the income requirements listed above
To qualify you must certify you do not currently have vision insurance coverage for yourself or the person(s) you are requested free care and glasses for.
I do not have vision insurance
I agree to attend the August 4th or 5th We CARE Veterans Fair at the Cobb County Civic Center to receive the free eye exam and glasses, ten minutes prior to my appointment time. Appointments will be scheduled after this form is received.
I do not agree
Please verify that you are human
Should be Empty: