PBTX Adult Vision Screening Request Form

 

Please fill out the information below. If Prevent Blindness Texas is able to participate, we will send a fax or email a confirmation.

If you would like Prevent Blindness Texas to conduct a screening at your event, please be prepared to provide the following: 2 tables, 6-8 chairs, an electric outlet for 2 equipment items, a small trash bin, and a quiet indoor location (away from bright daylight).

 

*1.



(Maximum response 255 chars, approx. 5 rows of text)

 2.

Additional contact information

*

Name:

 

 

   

*

*

 

*

City/State/ZIP:

 

    

*

 

 

 


 3.



(Maximum response 255 chars, approx. 5 rows of text)

 4.



(Maximum response 255 chars, approx. 5 rows of text)

 5.



*6.



(Maximum response 255 chars, approx. 5 rows of text)

*7.



(Maximum response 255 chars, approx. 5 rows of text)

*8.



(Maximum response 255 chars, approx. 5 rows of text)

*9.



(Maximum response 255 chars, approx. 5 rows of text)

*10.



*11.




*12.

Event type


*13.

Population


*14.

 


*15.




*16.



(Maximum response 255 chars, approx. 5 rows of text)

*17.




*18.




*19.



   Please leave this field empty

     

Copyright © 2007 Prevent Blindness America ®
 
 
Home   Contact Us   Privacy   Disclaimer
Prevent Blindness America