Dr. Furlong’s Gift of Sight program was started in 2002.
To date, we have donated over $1,185,000 in free treatment to deserving individuals.
Do you know someone in our community who is deserving of receiving our Gift of Sight?
Complete the application below.

Read more about this amazing program and the life-changing difference it has made for our patients.

Gift of Sight Application

Legal Name *

First

Last

Date of Birth *

Address

City

State

Zip Code

Home Phone Number *

Mobile Phone Number *

Email *

Preferred Method of Contact

When was your last eye exam?

Do you have a regular eye doctor?

If yes, name of regular eye doctor?

Have you ever been told that you had cataracts or any other eye conditions? Yes/No

If yes, please describe.

The Furlong Vision Correction "Gift of Sight" program continues to broaden its reach and expand its offerings to provide life changing vision correction to deserving individuals who have an enduring commitment to their communities and who cannot afford vision correction but will greatly benefit from the procedure. Number of household members (including self):

Household Adjusted Income:

Do glasses or contact lenses interfere with your quality of life? If so, please describe how they affect your life. *

How will vision correction improve your quality of life? *

If you are a recipient of the program, you agree to follow all medical care instructions, obtain and use medications as prescribed, keep all medical appointments as scheduled and be present at each appointment on time. You will be asked to give details about your personal life, work experience, vision history and to participate in marketing, social media and public relations efforts. Furlong Vision Correction (FVC) will issue news releases and post social media updates (with photos and/or videos) to inform the community and partners about the Gift of Sight program, the 2022 patients and their extraordinary stories. If news outlets are writing or producing an article or story, we will want you to participate if reporters want to discuss the success of your vision correction procedure with you. I understand that if I am one of the recipients of the Gift of Sight program, I agree to the conditions as listed above, and will willingly participate in these efforts as requested. If for any reason I am unable to meet these conditions, I understand that my participation in the program may be rescinded immediately. Please enter your name and date to acknowledge and digitally sign this form:

If you have any questions, please call Carla at (408) 453-5600 x 127

Furlong Vision Correction
Gives Back.

Apply now for the Gift of Sight

Gift of Sight Application

Gift of Sight Application

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