Online Pre-Application Begin Our Eligibility Quiz for Services Applicant Name Email Address Phone Number Mailing Address Which program are you applying for? Which program are you applying for? Eye Surgery Eyeglasses Vision Technology Do you have health insurance? Do you have health insurance?YesNo Have you had an eye exam by an ophthalmologist? Have you had an eye exam by an ophthalmologist?YesNo Name of Facility Name of Physician Submit Application