Appointment Request Form (d) Please fill in the form below to setup an appointment.Patient Type*New patientReturning patientPlease 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.Name* First Last Date of Birth* Date Format: MM slash DD slash YYYY Phone*Email* Best Time to be Reached for Confirmation* : HH MM 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?YesNoFirst and Last Name of the PrimaryDate of Birth of the Primary Date Format: 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?CommentsPhoneThis field is for validation purposes and should be left unchanged.
