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