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).

All Children See services are not yet in your area, I am sorry we cannot help you at this time. Please check back periodically for updates as we expand our services to other regions. If you are interested in eye screenings, local Lions clubs provide free and discount eye care, including surgeries, for people in need. School nurses, primary care providers, and our resources page may also be able to help.

Not Eligible - We're sorry we are not able to help you at this time. To qualify as an All Children See patient, a child must:

Be under the age of 18
Be a legal citizen/resident of the U.S.
Have failed an eye screening, be unable to complete a vision screening, or have an eye concern
Be uninsured or financially unable to pay a co-pay

If you are interested in eye screenings, school nurses, primary care providers and local Lions clubs may be able to help or visit our resources page.

Eligible

Child's age?(Required)

What is your child's date of birth?

Organization Name (If applicable)

Email(Required)

Phone(Required)

Patient ID

Hidden

Doctor

Hidden

PID