Request 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.

After this form is printed and reviewed by our front desk they will choose one of the three appointment requests and will call you to inform you when your appointment is scheduled. If we can not give you any of your requested appointments then our staff will call you to make the appointment over the phone.

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

Use the form below to request an appointment.

 Your Information
Last Name:
First Name:
Birth Date: MM/DD/YYYY
Email:
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?
   
 Your Appointment
Appointment Request #1:
Date: MM/DD/YYYY
Time: XX:XX AM/PM
Doctor:
Location:
Appointment Request #2:
Date: MM/DD/YYYY
Time: XX:XX AM/PM
Doctor:
Location:
Appointment Request #3:
Date: MM/DD/YYYY
Time: XX:XX AM/PM
Doctor:
Location:
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.
 
 
     
 
 
 
 
 
   
   
   
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