Patient Submission Form -

PATIENT INFORMATION

Name:

Date of Birth:

Gender:

Female Male

Marital Status:

Single Married Divorced Widowed

Current Address:

Address 2:

City:

State:

ZIP Code:

Home Phone:

Mobile Phone:

Email:

EYE CARE SERVICES

Have you received a formal cataract diagnosis?

Yes No

Which Eye?

Right Left Both

Last Exam Data:

Doctor Name/Location of Last Exam:

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

Yes No

If yes, please explain:

Do you have notes from your doctor visit?

Attached Please contact Dr.

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

PATIENT INSURANCE STATUS

Do you have insurance?

Yes No

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

Yes No

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?

Yes, I would be willing to share my responses and disclose my name. Yes, I would be willing to share my responses, but would prefer my name to not be disclosed. No, I would not like to share my responses.

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

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

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

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 $

SSN

Month $

SSI

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 $

SSN

Month $

SSI

Month $

Pension Retirement

Month $

Child Support

Month $

Other

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 $

SSN

Month $

SSI

Month $

Pension Retirement:

Month $

Child Support:

Month $

Other:

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 $

Social Security: