Patient Application Form

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Patient Application Form

All Children See services are currently operating in the following areas: Virginia, Washington DC, Maryland, New Hampshire, Indiana, Dallas, Texas. 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 and care 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?*

Do you have a concern about your child's eyes?*

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

Did the child fail OR was unable to complete the vision screening?

Does your child have medical insurance?*

Would out-of-pocket costs (copay or deductible) stop you from seeking eye care for your child?*

Child's name?*

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)*

The Child’s address (where child resides)*

State (ACS Active States Only)*

Is your mailing address the same as the Child’s physical address?*

State (ACS Active States Only)