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Omni Eye Foundation

Please include income and employment information for ALL members of the household. This includes children.

  • PATIENT INFORMATION
  • PATIENT EMPLOYMENT INFORMATION
  • HOUSEHOLD INCOME AND ADDITIONAL EMPLOYMENT INFORMATION
  • EYE CARE SERVICES
  • PATIENT INSURANCE STATUS

PATIENT INFORMATION

Name:

Date of Birth:

Gender:

Marital Status:

Current Address:

Address 2:

City:

State:

ZIP Code:

Home Phone:

Mobile Phone:

Email:

PATIENT EMPLOYMENT INFORMATION

Employer Name:

Occupation:

Wages/Tips (Before Taxes):

List Amount Selected: $

Average Hours Worked Per Week:

Please check this box if you did not file tax returns:

Other Income

Week $

Month $

Month $

HOUSEHOLD INCOME AND ADDITIONAL EMPLOYMENT INFORMATION

Household Member Name (1):

Is this member a child?

Employer Name:

Occupation:

Wages/Tips (Before Taxes):

List Amount Selected: $

Average Hours Worked Per Week:

Please check this box if you did not file tax returns:

Other Income

Week $

Month $

Month $

Month $

Month $

Month $

Household Member Name (2):

Is this member a child?

Employer Name:

Occupation:

Wages/Tips (Before Taxes):

List Amount Selected: $

Average Hours Worked Per Week:

Please check this box if you did not file tax returns:

Other Income

Week $

Month $

Month $

Month $

Month $

Month $

Household Member Name (3):

Is this member a child?

Employer Name:

Occupation:

Wages/Tips (Before Taxes):

List Amount Selected: $

Average Hours Worked Per Week:

Please check this box if you did not file tax returns:

Other Income

Week $

Month $

Month $

Month $

Month $

Month $

Household Member Name (4):

Is this member a child?

Employer Name:

Occupation:

Wages/Tips (Before Taxes):

Average Hours Worked Per Week:

Please check this box if you did not file tax returns:

Other Income

Week $

Month $

Month $

Month $

Month $

Month $

EYE CARE SERVICES

Have you received a formal cataract diagnosis?

Which Eye?

Last Exam Data:

Doctor Name/Location of Last Exam:

Have you been diagnosed with any other eye conditions or diseases?

If yes, please explain:

Do you have notes from your doctor visit?

What is the maximum distance you can travel for your surgery and appointments (in miles)?

PATIENT INSURANCE STATUS

Do you have insurance?

If no, have you applied for state or county medical assistance?

Please list reason for ineligibility for state or county assistance (if applicable):

ADDITIONAL PATIENT INFORMATION

Please tell me how you first heard of Operation Gratitude.

What kind of change will this procedure have on your life?

Operation Gratitude relies on the generosity of volunteer surgeons and donations. What could you tell someone who was trying to decide if they should volunteer or donate to this program?

Why do you feel it’s important to have programs like Operation Gratitude?

Would you be willing to share your responses to help raise awareness about Operation Gratitude?

PLEASE PROVIDE ANY ADDITIONAL INFORMATION REGARDING INTERESTS, DAILY ACTIVITIES, AND HOBBIES.

I declare that all parts of this application are true and correct statements, to the best of my knowledge. I understand that the details of this application are soley used to determine my overall financial status and possible eligibility for Operation Gratitude.

Signature of Applicant:

Date:

PLEASE SUBMIT YOUR COMPLETED APPLICATION FORM AND THE ADDITIONAL REQUESTED DOCUMENTATION TO: OmniEyeFoundation@OOMC.com or by fax to: 732-510-2542