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Apply for Vision Assistance
Atomic Dev
2025-08-20T16:36:20-05:00
Apply For Vision Assistance
Need help with vision care? Fill out the form below to apply for assistance and take a step toward clearer sight.
Fill out the form to apply:
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By checking this box, A) I agree to receive texts from Now-Forward at the mobile number listed on your application. B) I have read the guidelines and basic requirements on the previous page, and I agree that completing the application does not guarantee assistance. C) I also agree that all information I provide is accurate and truthful and understand that if any information is not provided or is inaccurate my request for assistance will be closed without consideration.
(Required)
Yes
EYEGLASSES APPLICATION
MUST BE FILLED OUT BY ADULT OVER 18 - IF SEEKING ASSISTANCE FOR A CHILD, THEIR NAME AND AGE CAN BE TYPED IN BELOW IN SECTION "PATIENT UNDER 18 YEARS OLD"
If more than one person in household needs a pre-screening and they are over 18, you can list them in the "Brief explanations" section at bottom of application.
THIS MUST BE COMPLETED BY THE HEAD OF HOUSEHOLD – 18 AND OVER
(Required)
First
Middle
Last
Address
(Required)
Street Address
Apt #
City
State
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
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Montana
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New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
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Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
ZIP Code
Telephone Number
(Required)
Email Address
(Required)
HEAD OF HOUSEHOLD INFORMATION
Now-Forward Client Number
If you already have a Now-Forward client number, please enter it here to expedite processing your request. If you do not have a client number, please leave this blank.
Official Photo ID #
(Required)
Gender
(Required)
Select One
Male
Female
Date of Birth
(Required)
MM slash DD slash YYYY
Ethnicity
(Required)
Select One
White
Bi-Racial
Black
Hispanic
Asian
Other
Marital Status
(Required)
Select
Single
Living Together
Engaged
Married
Common Law
Separated
Divorced
Widowed
Is the patient under 18 years old?
No
Yes
PATIENT UNDER 18 YEARS OLD
Patient's Name
First
Middle
Last
Patient's Gender
Select one...
Male
Female
Patient's Date of Birth
MM slash DD slash YYYY
EYEGLASSES ASSISTANCE NEEDED
Brief explanation of why you need this help?
(Required)
YOU MAY BE REQUIRED TO MAKE 2-3 VISITS TO NOW FORWARD. 1 - FOR PRE-SCREENING TO SEE IF YOU NEED A PRESCRIPTION AND/OR READERS. 2 - FOR ACTUAL VISIT TO GET PRESCRIPTION IF NEEDED. 3-TO PICK UP YOUR EYEGLASSES WITH PRESCRIPTION.
If you fail to come in for your pre-screening within 5 days, your file will be closed and you will have to reapply.
A RESPONSE WILL BE EMAILED TO YOU WITHIN 2-4 DAYS ONCE YOU SUBMIT.
PLEASE READ SCREEN AFTER YOU CLICK SUBMIT FOR IMPORTANT DIRECTIONS.
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