Medical Card Vision Test Application Form
Apply for a medical card vision test by providing your contact details, vision-related information, and appointment preferences if needed.
Applicant Information
Full Name
*
First Name
Middle Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
Preferred Contact Method
*
Phone
Email
Text Message
Other
Vision Test and Medical Details
Do you wear glasses or contact lenses?
*
No
Glasses
Contact lenses
Both glasses and contact lenses
Current vision correction type
Please Select
None
Single-vision glasses
Bifocal or multifocal glasses
Contact lenses
Both glasses and contact lenses
Other
Reason for vision test/application
*
Please Select
Initial application
Renewal
Vision change
Required medical review
Other
Known vision difficulties
Blurred vision
Difficulty seeing at night
Difficulty reading small print
Double vision
Glare sensitivity
Color vision difficulty
Peripheral vision loss
No known difficulties
Other
Have you had a prior eye exam?
*
Yes
No
Relevant medical or eye condition notes
Appointment and Submission Preferences
Preferred appointment date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Preferred appointment time
Hour Minutes
AM
PM
AM/PM Option
Preferred testing location / branch
Please Select
Main Clinic
Downtown Branch
Northside Branch
Other
Submit Application
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