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?*

I am seeking a referral for my child. I am seeking a referral on behalf of someone else's child.

Does the child reside in one of the following:*

Virginia Washington DC Maryland New Hampshire Indiana Dallas/Fort Worth

Is the child a US citizen/legal resident?*

Yes No

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

Yes No

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

Yes No

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

Yes, child failed Yes, child could not complete No, child passed

Does your child have medical insurance?*

Yes No

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

Yes No

Child's name?*

First Name

Last Name

Child's age?*

What is your child’s date of birth?

What is your relationship to this child?*

Mother Father Friend Health Professional Legal Guardian Other:

What is your name?*

Your First Name

Your Last Name

Organization Name (if applicable)

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

Website/Internet Search/Facebook/Twitter/Social Media Social Service Agency/Eye Screening Head Start Nurse/Doctor Other:

Patient Application Form