Idaho Lions Vision Clinic Apply for Vision Clinic & Hearing Aid Assistance Name * First Name Last Name Email * Address Address 1 Address 2 City State/Province Zip/Postal Code Country Phone * (###) ### #### Sex * Date of Birth * Emergency Contact First Name Last Name Relationship to patient * Phone (###) ### #### Medical History Date of your last exam? Do you currently wear eyeglasses? Yes No If so, how old is your current pair? Do you have health or vision insurance? if so, please list carriers Are you diagnosed with Diabetes? Are you pregnant? Income How many people are in your household? Income of Applicant Please include all sources of income. $ Income of other members of the household $ If no income, how are you supported at this time? Service Requested Eye Exam AND Glasses Glasses Only, (A valid prescription is required.) Hearing Aid Assistance Social Worker/Advocate If you are filling this application for a paitent, client, or friend pelase leave your information. First Name Last Name Agency Phone (###) ### #### Thank you for your application. Please allow 3-5 business days for one of our coordinators to reach out to you via phone and/or email.
