Please fill in the form below to setup an appointment.

Patient Type*

New patient
Returning patient

Please let us know if you are a new or existing patient.

Reason for Appointment*

Please provide a reason for your appointment. Is this a routine exam for glasses, contact lenses, or are you having a medical eye issue? Details are stored securely and not sent by email.

Preferred Date & Times*

Please let us know when you would prefer to have your appointment. Our hours are listed on our location page. PLEASE NOTE: The specific date and time that you prefer may not be available.

Do you have a preference as to which doctor you see? (Choose no preference if you want the most appointment scheduling options)*

Name*

First Last

Date of Birth*

Phone*

Email*

Best Time to be Reached for Confirmation

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Insurance

What is the name of your vision insurance (example: VSP, Spectera, Davis, etc. or NONE)?*

What is the name of your medical insurance (example: Medicare, Regence Blue Cross, United Health Care, Aetna, etc. or NONE)?*

Are you the primary?

Yes
No

First and Last Name of the Primary

Date of Birth of the Primary

Medical Insurance ID number:

Medical Insurance Group number:

Last 4 digits of the Social Security Number of the Primary:

What's the name of the employer it's through?

May we have a cell phone number to reach you about your appointment request?

Comments

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