Appointment Request Form (d) 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)*No preferenceDr. Scott LewisDr. Jessica WalkDr. John ThompsonDr. Vladimir StovbyrDr. Craig JordanName* First Last Date of Birth* MM slash DD slash YYYY Phone*Email* Best Time to be Reached for Confirmation* : Hours Minutes AM PM InsuranceWhat 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 MM slash DD slash YYYY 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? CommentsCommentsThis field is for validation purposes and should be left unchanged.
