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 *

Zip *

Home Phone *

Cell Phone *

Email Address *

Gender *

Female

Male

Date of Birth *

Ethnicity *

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 *

EMERGENCY CONTACT

FOR OFFICE USE ONLY