Charitable Product Request

Over our company’s 35-year history, one of the ways that we have sought to help preserve and enhance vision for all of humanity is by providing no-charge products for patients unable to afford care. If an ophthalmic surgeon is willing to donate their efforts, New World Medical is eager to supply them with empowering technology to benefit patients in need.

Complete the Charitable Product Request Form

Please complete the online product request form. We will review your submission and respond within two weeks. If your circumstances are more pressing, please call our offices during normal business hours at toll-free (800) 832-5327 or our local number (909) 466-4304.

Once you have utilized the product or returned from your mission trip, please complete the Humanitarian Outcomes Report. The information you provide will help New World Medical to enhance its efforts to support your admirable work.

Fields marked with an asterisk (*) are required.

Requester Name

Please enter your email so we can get in touch.

Surgeon Name
Practice Address
Request Type 
Please select the medical mission type from the following 
Will the surgeon be providing services to patients free of charge ?

Including surgery fees and hospital fees

Is the surgeon aware of New world Medicals local distributor in the market? 
Destination / Location

Please list destination of Medical Mission or location where the humanitarian products will be used

Where surgery will be performed

If any

Product Specific Information

Product Usage Start Date 
Product Usage End Date 
Which Product(s) Are You Requesting? 

Ahmed Glaucoma Valve FP7

Date Needed 

Ahmed Glaucoma Valve FP8

Date Needed 

Ahmed ClearPath 250

Date Needed 

Ahmed ClearPath 350

Date Needed 
Date Needed 

KDB GLIDE / Kahook Dual Blade

Date Needed 
Address where you would like the products to be shipped

Share Your Story

If you’ve received a charitable product donation, please tell us about your medical mission.

Share Your Story