Patient Application Form

All Children See services are currently operating in 29 states and Washington D.C. 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).

Please note that extended wait times for ACS appointments are not a reflection of cost of care. There is currently a global shortage of pediatric ophthalmologists. The American Association for Pediatric Ophthalmology and Strabismus is actively working to attract and retain new talent into this important healthcare field. We thank you for your patience as we work to provide care to patients as soon as possible.

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

A doctor must be selected on the next screen to ensure being seen.