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Vision Care Request Form
Broken Arrow Neighbors is currently providing low cost vision care to individuals within the area that have NO health insurance or other feasible outlet for this type of service. If you think you can benefit from this program, please fill out the following information, and you will be added as a potential patient for our clinic. A representative of BAN will email or call you to set up an appointment. Please know that it may take several months to receive vision care.
Date
Name
*
First
Last
*
Last
Address
*
City
*
State
*
Alabama
Alaska
Arkansas
Arizona
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zip
*
Home Phone
*
Cell Phone
*
Email Address
*
Gender
*
Female
Male
Date of Birth
*
Ethnicity
*
African American
Asian/Pacific Islander
Caucasian/White
Hispanic
Native American
Other
If 'Other,' please explain here:
If this is your first visit to our clinic, how did you hear about us?
Are you or a family member covered by SoonerCare?
*
Yes
No
Do you have health insurance?
*
Yes
No
When was the last time you saw an eye doctor?
Please explain what vision problems you are currently having:
EMERGENCY CONTACT
Name
*
First
Last Name
*
Last
Relationship
*
Phone Number
*
FOR OFFICE USE ONLY
If you are human, leave this field blank.
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