Roholt Vision Institute

N.CANTON, OHIO:
330.305.2200

CANFIELD, OHIO:
330.702.8755

ALLIANCE, OHIO:
330.829.2311
MILITARY FORM


                  
       DR. ROHOLT SUPPORTS OUR MILITARY

Are you currently serving or have served in active duty with the military since 9/1/01?  If yes, complete & submit the questionnaire to be considered for FREE Lasik surgery performed by Philip Roholt, M.D.

 

                                                             This is for a limited time only.

 

* Required Information
*Nominee:
 
Address:
 
City:
 
State:
 
Zip:
 
Age:
 
Home Phone:
  
Cell Phone:
 
*Email:
 
Are you married?
  Yes   No
Do you have children?
  Yes   No
Ages of children:
  
Do you wear contacts or glasses or both?
   Contacts   Glasses
How long?
  
If you know your prescription, please tell us?
  
To which branch of the armed forces do you belong?
  
For how many years?
  
Have you served on active duty since 9/11/01 to Iraq or Afghanistan?
   Yes   No

If yes, list dates served and where:


Were you injured while on active duty or training?


What is one thing that stands out from your activity duty that you would like to share?


In 50 words or less, tell us why Roholt Vision should select you or the person nominated to receive FREE Lasik.

Nominated by:
 
Relationship:
 

Proof of serving in active duty will be required.

 

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If you have questions, or would like to schedule a free Laser Vision Correction consultation, please call us at 330-305-2200 or at 1-800-481-5273 (LASER).

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