Free DILATED Eye Exam Application

Application for DILATED Eye Exam

Thank you for applying for our EEP Program. 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.

*1.WHO is requesting an eye exam?(Required.)

First Name

Last Name

*2.Address:

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

Address

City/Town

State/Province

ZIP/Postal Code

Email Address

Phone Number

3.What color are your eyes?

Blue

Brown

Hazel

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

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

Yes, near-sighted

Yes, far-sighted

Yes, stigmatism

Yes, other

No, I do not wear glasses for any reason

6.Do you currently use SUNGLASSES?

Yes

*7.Does someone you know have Ocular Melanoma?(Required.)

Yes, an immediate family member

Yes, a friend

Yes, I do

NO, just would like to have an eye exam

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

9.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.
3. Page 1 and 2 of your most recent 1040 tax return.

10.Where will your eye exam take place?

Name of Provider/Business

Address of Provider

Telephone number of Provider

Provider's EIN number

Cost of DILATED eye exam to be performed

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