Eye Clinic Intake Form First Name* Last Name* Email* Phone*Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Birth Date MM slash DD slash YYYY AgeHome PhoneMessage or Cell PhoneMay we leave a message? Yes No Number at which to leave a message: Email Have you ever received assistance from the Haskell Eye Clinic? Yes No What assistance are you requesting* Eye Exam Glasses Do you need ADA accomodations? Yes No Please explain ADA accommodations needed: Do you have Medicare? Yes No Do you have Medicaid? Yes No Other Please detail other insurance coverage: Do you have any other vision insurance? Yes No If you have Medicare/Medicaid or other public health coverage, you must obtain an exam from a clinic accepting this coverage. A list is available on request.What is your housing status Own Rent Staying with family/friends Homeless Other Please explain Other housing status: Employment Status Employed Full-Time Employed Part-Time Temporary Self-employed Not employed but looking for work Not employed and not looking for work Retired Student Gender Male Female Prefer Not to Answer Marital Status Single Married Divorced Widowed Financial InformationTO QUALIFY: 1. PRIORITY WILL BE GIVEN TO WHATCOM COUNTY RESIDENTS 2. MUST MEET FINANCIAL INCOME GUIDELINES BELOWDo you have dependent children living with you? Yes No How many dependent children live with you?Total number of people in household, including yourself:Monthly Salary:
