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Patient Application Form

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Patient Application Form

All Children See is launching its pilot in Washington DC, Northern Virginia, Maryland, New Hampshire, and Indiana. We plan to expand nationally. Please check back here periodically for updates about our rollout if we are not yet in your area. You may also visit our resources page for other organizations that may help you.

Answer the following questions to determine whether a child you know qualifies for a medical eye exam provided by volunteer pediatric ophthalmologists (eye doctors).

Who are you seeking a referral for?*

Does the child reside in one of the following:*

Is the child a US citizen/legal resident?*

Who are you applying for?*

Child's age?*

What is your child’s date of birth?*

What is your relationship to this child?*

What is your name?*

How did you hear about us? (Please choose all that apply)*

State*

Is your mailng address the same as your physical address?*

State

Does your child have medical insurance?*

Is insurance co-pay or deductibles preventing you from seeking eye care for your child?*

Has your child had a vision screening in the last year?*

Did the child fail the vision screening?*