Patient Inquiry Form

Patient Inquiry Form

This is the first step in the Operation Sight screening process. Eligibility requirements: Must live within 250% of the Federal Poverty Level, must be a US citizen or permanent resident, must be uninsured or underinsured, must have a cataract diagnosis (deemed ready for surgery) no more than 18 months old. *If you have insurance that pays any amount of money toward cataract surgery, you are not eligible for Operation Sight. Operation Sight does not help pay deductibles, co-insurance, or co-pays for insured patients.
Patient Name*

First NameLast Name
Email *Please verify email address is correct*

Confirmation EmailFuture correspondence will be sent to this email address
Phone Number*

Country CodeArea CodePhone Number
Date of Birth*
(dd/mm/year)
Patient's Physical Address (for matching purposes only)*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Have you previously submitted an inquiry form to Operation Sight?*

YesNo
If yes, what is the reason for your re-submission?*

Received a formal cataract diagnosisTreatment of additional eye conditions completedNo Longer InsuredChange of Financial SituationOther

Are you permanently residing in the United States?*
You need to be a U.S. Citizen or permanent resident to be eligible for Operation Sight.

Have you received an exam with a cataract diagnosis?*
*This diagnosis must be from an optometrist or ophthalmologist and meet the following requirements: occurred within the past 18 months, includes visual acuity score, and deemed medically necessary by your physician. Please note that you will be required to provide a copy of the formal cataract diagnosis exam during the application process.