Ophthalmologist / Optometrist Enrollment Form
Please complete the form below to become a Visual Freedom Foundation Ambassador.
The information you provide will be used to create your credentials for accessing the VFF website, recording surgeries, and viewing additional resources and information.
Sign in to Google to save your progress. Learn more
Full Name *
Credentials (MD/DO, etc.) *
Practice Name *
Point of Contact Name in your Practice *
Email Address *
Practice Address (street, suite, city, state, country, postal code) *
Preferred method of contact *
Required
As a Visual Freedom Foundation Ambassador, I commit to the following:

Advocate for equitable access to refractive care in my community and professional circles.

Volunteer my surgical expertise to provide free or low-cost refractive procedures for eligible patients.

Collaborate with VFF on outreach, referrals, or education initiatives when possible.

Represent VFF with professionalism and compassion, upholding its mission to serve those in need.

 *
Required
Thank you we will be in contact soon with next steps 
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