Mobile Clinic Request Form - Step 1


REQUEST A VSP EYES OF HOPE MOBILE CLINIC

Now accepting applications for 2027 events. We suggest submitting your request by October 1, 2026. (Our 2026 calendar is fully booked for the remainder of the year.)

To request a VSP Vision Eyes of Hope® mobile clinic to provide free vision care for disaster relief or for a population in need who qualifies, please fill out this form.

Questions? Contact us at mobileclinic@vsp.com.

 

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Your Info

Event Info

Event Details

All fields required unless otherwise noted.

Contact Information

Mailing Address

Practice/Organization Information

Are you a VSP Network doctor?

Mobile Clinic Request Form - Step 2

To request a VSP Eyes of Hope mobile clinic to provide free vision care for disaster relief or for a population in need who qualifies, please fill out this form.

Questions? Contact us at mobileclinic@vsp.com.

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Your Info

Event Info

Event Details

All fields required unless otherwise noted.

Type of Event (Check all that apply)

*Charitable, community-based, or educational events not related to disaster relief or vision care outreach considered on a case-by-case basis as our schedule permits.

A brief description of your event: Who will be helped, event details and event purpose, any additional organizations participating.

Event Start Date and Time

Events with less than three months’ notice will be declined. Multi-day events of seven or more hours each day will be given priority.

Event End Date and Time

Mobile Clinic Request Form - Step 3

To request a VSP Eyes of Hope mobile clinic to provide free vision care for disaster relief or for a population in need who qualifies, please fill out this form.

Questions? Contact us at mobileclinic@vsp.com.

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Your Info

Event Info

Event Details

Note: The event location must be able to accomdate a mobile clinic up to the following specifications:

Length: 45’
Height: 13’6”
Width: 12’ (parked); 8’6” (traveling)
Weight: 38,000 lbs

All fields are required unless noted.

TYPE OF PATIENTS (CHECK ALL THAT APPLY)
Patients must qualify* to receive care onboard the VSP Eyes of Hope mobile clinic.

*Eligibility
All services are offered on a first-come, first-served basis, for individuals who meet the following qualifications:

  • Family income up to 200% of the federal poverty level guidelines for your family’s size
  • No coverage through a private insurer and/or a government program for the services to be provided
  • Haven’t received services through a VSP program during the last 12 months