Military Form - Roholt Vision Institute - Philip Roholt, MD, ABES

* 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.