EyeCare America® Partner Request Form

Thank you for helping to spread the word about EyeCare America and eye health. We are happy to provide complimentary materials, while supplies last. Questions? Email eyecareamerica@aao.org.

1. Is this your first time ordering materials? *This question is required.

2. How have you used the materials to date? (check all that apply) *This question is required.

Distributed at Health Fair
Distributed in Office
Distributed Direct to Client / Patient
Gave Presentation to Client / Patient
Included in Newsletter
Included on Social Media
Posted on Website
Other Please enter an 'other' value for this selection.

2. Have a picture of our materials in use? We would love to see it.

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2. How did you hear about EyeCare America? *This question is required.

Please enter an 'other' value for this selection.

2. Digital Materials

Kindly indicate the digital materials you would like to receive: (check all that you would like to receive)

Banner advertisement for your website
PowerPoint Presentation to share with your members / attendees / clients
Flyer to share with your members / attendees / clients
Information to include in your newsletters
Other item(s) you are interested in, we will do our best to accommodate your request Please enter an 'other' value for this selection.

3. Eye Health Print Materials

Kindly indicate the print materials on eye health topics you would like to receive and the quantity you would like of each: (check all that you would like to receive)

AMD (Age-related Macular Degeneration) Risk Factor Card Please enter an 'other' value for this selection.
Dry Eye Brochure (English) Please enter an 'other' value for this selection.
Dry Eye Brochure (Spanish) Please enter an 'other' value for this selection.
Eye Facts and Myths Brochure Please enter an 'other' value for this selection.
Glaucoma Risk Factor Card (English) Please enter an 'other' value for this selection.
Glaucoma Risk Factor Card (Spanish) Please enter an 'other' value for this selection.
Low Vision Brochure Please enter an 'other' value for this selection.
Seeing Well as You Grow Older Brochure Please enter an 'other' value for this selection.

4. EyeCare America Print Materials

Kindly indicate the EyeCare America print materials you would like to receive and the quantity you would like of each: (check all that you would like to receive)

EyeCare America Bookmark Please enter an 'other' value for this selection.
EyeCare America Drug Discount Card Please enter an 'other' value for this selection.
EyeCare America Program Brochure (English) Please enter an 'other' value for this selection.
EyeCare America Program Brochure (Spanish) Please enter an 'other' value for this selection.
EyeCare America Flyer Please enter an 'other' value for this selection.

5. As we consider creating new materials, let us know what you would find useful for your members / attendees / clients / patients?

6. Contact Information

Kindly provide your contact information. The materials will be emailed and/or mailed to the address provided:

First Name *This question is required.

Last Name *This question is required.

Title *This question is required.

Organization Name *This question is required.

Street Address

Apt/Suite/Office

City

State *This question is required.

Zip

Email Address *This question is required. This question requires a valid email address.

Phone Number

Mobile Phone

7. Type of Organization *This question is required.

8. Newsletter

By checking this box you consent to EyeCare America's bi-yearly newsletter containing eye health and program information that will help in providing information to your members / attendees / clients / patients.

9. Comments and/or Questions