Patient Inquiry Form
This is the first step in the Operation Sight screening process.
Patient Name
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First Name
Last Name
Email *Please verify email address is correct
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Confirmation Email
Future correspondence will be sent to this email address
Phone Number
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Country Code
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Area Code
Phone Number
Date of Birth
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(dd/mm/year)
Patient's Physical Address (for matching purposes only)
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Have you previously submitted an inquiry form to Operation Sight?
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Yes
No
If yes, what is the reason for your re-submission?
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Received a formal cataract diagnosis
Treatment of additional eye conditions completed
No Longer Insured
Change of Financial Situation
Other
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Are you permanently residing in the United States?
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Yes
No, I am temporarily visiting
You do not need to be a U.S. Citizen to be eligible for Operation Sight
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Have you received an exam with a cataract diagnosis?
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Yes
No
*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.
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Approximately when did you receive your exam with a cataract diagnosis?
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Within the past 12 months
Within the past 24 months
More than 2 years ago
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Do your exam notes indicate you were diagnosed with additional eye conditions?
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Yes
No
If yes, select any additional eye conditions you have been diagnosed with
Astigmatism
Coloboma
Diabetic Retinopathy
Dry Eye
Farsightedness (Hyperopia)
Glaucoma
Macular Edema
Macular Hole
Macular Pucker
Nearsightedness (Myopia)
Presbyopia
Retinal Detachment
Uveitis
Vitreous Detachment
Other
Do your additional eye condition(s) require treatment prior to cataract surgery?
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Yes
No
Not sure
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Do you have insurance?
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Yes
No
If your insurance is pending, please select "yes"
List the Details of your Insurance
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Insurance plan, Insurance Company
Do You Receive Any Government Healthcare Aid?
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Medicare
Medicaid
None
Other
What Type of Medicare?
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Part A
Part B
Part C
Part D
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How did you hear about Operation Sight?
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Google/Web Search
Facebook
Twitter
Instagram
EyeCare America/ American Academy of Ophthalmology (AAO)
Mission Cataract
Doctor Referral
Other
Include Referring Doctor's Full Name and Practice (if applicable)
*
Please provide any additional information you would like to share:
By submitting this inquiry form, I understand and accept to the following terms and conditions:
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This is not the official application. If I am eligible, I will need to submit additional documentation required via the Operation Sight screening process.
Operation Sight charitable cataract surgeries are provided on a voluntary basis. Surgery is not guaranteed. End of year is a busier period for volunteer surgeons. If you are approved after the entire application process, please note surgery may not be scheduled until 2025.
The program does not provide financial assistance with insurance co-pays, deductibles, or out of pocket expenses such as travel.
I will receive an email within 5-7 business days regarding my eligibility for the next step in the screening process.
I declare that all parts of this inquiry form are true and accurate statements, to the best of my knowledge. Please sign below:
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