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Schedule an Appointment

This page is for your convenience, instead of having to call us all you need to do is fill in the following boxes and click send. This request form is sent to an e-mail address that is checked daily. If you’re a new patient you can use this too! Just send the request in and print out the Patient Health History Form and the Insurance Release Form, fill out the forms and bring them in when you come in for your appointment.

** This appointment request form is not to be used for emergencies **

** Cancellations must be made 24 hours in advance of your scheduled appointment. If you need to cancel, please leave contact information so we can get in touch with you to reschedule your appointment. **

Use the form below to request an appointment.

Fields marked with an (*) are required

Name: Add your name

Birthdate: MM/DD/YYYY

Email: Add a valid address

Phone Number: (555) 555-5555

Do you have or suspect you have glaucoma?

Do you have or suspect you have a cataract?

Do you have diabetes?

Do you wear or are interested in wearing contacts?

Appointment Request #1:

Date:MM/DD/YYYY

Time:XX:XX AM/PM

Doctor:Add name

Location:Select city of choice

Appointment Request #2:

Date:MM/DD/YYYY

Time:XX:XX AM/PM

Doctor:Add name

Location:Select city of choice

Appointment Request #3:

Date:MM/DD/YYYY

Time:XX:XX AM/PM

Doctor:Add name

Location:Select city of choice

If you are a new patient please remember to print and fill out the Patient Health History Form and Insurance Release Form to bring with you to your appointment.

Schedule an Appointment

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Advanced Eye Centers locations in Massachusetts including New Bedford, North Dartmouth, Taunton and Fall River.