Mobile Clinic Request Form - Step 1


REQUEST A VSP EYES OF HOPE MOBILE CLINIC

To request a VSP Vision Eyes of Hope® mobile clinic to provide free vision care for disaster relief or for a population in need who qualifies, please fill out this form.

Questions? Contact us at mobileclinic@vsp.com.

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Your Info

Event Info

Event Details

All fields required unless otherwise noted.

Contact Information

Mailing Address

Practice/Organization Information

Are you a VSP Network doctor?

Mobile Clinic Request Form - Step 2

To request a VSP Eyes of Hope mobile clinic to provide free vision care for disaster relief or for a population in need who qualifies, please fill out this form.

Questions? Contact us at mobileclinic@vsp.com.

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Your Info

Event Info

Event Details

All fields required unless otherwise noted.

Type of Event (Check all that apply)

*Charitable, community-based, or educational events not related to disaster relief or vision care outreach considered on a case-by-case basis as our schedule permits.

A brief description of your event: Who will be helped, event details and event purpose, any additional organizations participating.

Event Start Date and Time

Events with less than three months’ notice will be declined. Multi-day events of seven or more hours each day will be given priority.

Event End Date and Time

Mobile Clinic Request Form - Step 3

To request a VSP Eyes of Hope mobile clinic to provide free vision care for disaster relief or for a population in need who qualifies, please fill out this form.

Questions? Contact us at mobileclinic@vsp.com.

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Your Info

Event Info

Event Details

Note: The event location must be able to accomdate a mobile clinic up to the following specifications:

Length: 45’
Height: 13’6”
Width: 12’ (parked); 8’6” (traveling)
Weight: 38,000 lbs

All fields are required unless noted.

TYPE OF PATIENTS (CHECK ALL THAT APPLY)
Patients must qualify* to receive care onboard the VSP Eyes of Hope mobile clinic.

*Eligibility
All services are offered on a first-come, first-served basis, for individuals who meet the following qualifications:

  • Family income up to 200% of the federal poverty level guidelines for your family’s size
  • No coverage through a private insurer and/or a government program for the services to be provided
  • Haven’t received services through a VSP program during the last 12 months