Application for Eye Exam

Thank you for applying for our EEP Program which we have started in 2020.  Through this program, we will provide an option for early detection of Ocular Melanoma, an insidious eye cancer.  Once this cancer metastasizes, there is no known cure.  Early detection and awareness provides the best chances for catching Ocular Melanoma early enough to provide treatment.

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* 1. WHO is requesting an eye exam?

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* 2. Address: 

Please provide verification information to:  info@ocularmelanoma.org
* Driver's license or picture ID card (Picture of front and back)

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* 3. What color are your eyes?

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* 4. Have you been diagnosed with any eye issues? If so, what?

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* 5. Do you wear glasses for any type of eye deficiencies?

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* 6. Do you currently use SUNGLASSES?

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* 7. Does someone you know have Ocular Melanoma?

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* 8. If you answered YES to Q7 above, please name the person.

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* 9. Where will your eye exam take place? 

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* 10. How did you hear about Ocular Melanoma Foundation’s Eye Exam Program?

Thank you for taking the time to complete this application. 
Please remember to send additional items to: info@ocularmelanoma.org

1. Driver's license or picture ID card (must have your address as shown on application.
2. Please provide an appointment card and cost from the Provider who will perform the DILATED EYE EXAM on you.

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