Website Survey

Financial assistance inquiry

We work hard to make our screens affordable. If you don't have insurance or are unable to pay your bill in full, please enter your information below and we will be in touch.

Tell us about yourself

Just need some basic information so that you can save your calculated financial assistance.

Counsyl info

If you've already ordered a screen, we can apply your financial assistance to your order.

Insurance info

We'll need to look up your insurance information to generate your price estimate.

My insurance company is not listed

The unique identifier given by your insurance.

The unique identifier given by your insurance.


We need this information to determine the appropriate amount of financial assistance.

Extra Info

If there are any extenuating circumstances you think we should consider, please share them with us.

Locate your invoice number or barcode number on any of the items shown below and enter above.

Barcode on the kit
Barcode on kit
Barcode on the card
Barcode on card
Invoice number
Invoice number
Total annual gross household income means the total income earned by all members of your household before taxes from any source (e.g., gross salary, unemployment compensation, disability, worker's compensation, Social Security benefits, public assistance, or other)