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Eyes of Hope Testimonial Form

Share a story about how seeing well has made a difference for you or someone you know. Please do not include any Protected Health Information (PHI) on this form.

All fields are required unless noted.

How did you receive eye care? (check all that apply)
What prompted you to seek eye care from Eyes of Hope? (check all that apply)

When was your last eye exam? If more than a year ago, what barriers have you had to receiving eye care? (optional)

Your Story:
Tell us about your eye exam, your glasses (if prescribed), and how they’ve helped you.

I, the undersigned, authorize Vision Service Plan, dba VSP Vision (“VSP”), and all its lines of business, subsidiaries and affiliates, as well as its/their directors, officers, employees, agents, representatives and/or contractors to release and discuss my protected health information (or information regarding the treatment, medical condition, or related topics, of my child or an individual to whom I provide guardianship).
I authorize and give permission to VSP and permission to use, reuse, distribute, publish, and republish, in whole or part, my and/or their testimonial(s), statement(s), and/or image(s) and information related to the diagnosis, treatment and healthcare services provided or to be provided, and which identifies my and/or their name and other personally identifiable information in any electronic, broadcast, printed and/or other form of medium, including all websites, blog and social media platforms maintained, operated by and/or affiliated with VSP in conjunction with its business related publicity and/or media relations activities.

  • I understand VSP may receive direct or indirect financial remuneration in connection with the use or disclosure of my information/images from a third party due to marketing.
  • I understand I will not receive any financial compensation for the use and disclosure of my information/image.
  • I understand I have the right to revoke this Authorization up until a reasonable time before my information/image is used by providing written notice to VSP.
  • I understand if I revoke this Authorization, my information may no longer be used or released for the reasons covered by this Authorization. However, I understand that any disclosure or publication made prior to a revocation may remain in public domain.
  • I release and agree to indemnify and hold harmless VSP from any and all liability, including, but not limited to, claims for libel and right to privacy, in connection with this matter.