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English (US)
Appointment Request Form
We appreciate your attention and patience in providing this important information. Current and accurate information is critical to our efficiently providing quality care, and state and federal "no surprises" laws require us to attempt to verify we are an in network provider for your insurance before your appointment.
Are your a new or pre-existing patient?
*
I am a new patient.
I am a pre-existing patient.
Patient Name
*
First Name
Last Name
Suffix
Patient Date of Birth
*
-
Month
-
Day
Year
Date
Contact Person Name ( if different)
First Name
Last Name
Preferred Phone Number
*
-
Area Code
Phone Number
Phone number above is
*
Mobile - and text messages are OK (preferred)
Mobile - but avoid text messages if possible
Home
Work
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
*
example@example.com
Medical Insurance Company - Type "SELF PAY" if none
*
Medical Insurance Number - Type " SELF PAY" if none
*
For the insurance above, the patient is:
*
the subscriber
the spouse/partner
a child/dependent
What is the insurance subscriber's name?
First Name
Last Name
What is the insurance subscriber's Date of Birth?
-
Month
-
Day
Year
Date
Do you have separate vision insurance ?
Yes
No
Please select vision insurance plan:
VSP
Eyemed
Davis Vision
Other
Vision Insurance Patient ID - for VSP, use the last 4 digits of your SSN.
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Due to the COVID19 concerns, we will be making every effort to minimize wait time as well as overlap of patients in the office. For this to be successful, we need to know what each patient hopes to accomplish as part of their visit so that we can schedule appropriately.
Please check all that apply:
My vision may have changed for the worse.
My vision problems are interfering with my daily function.
I have a new eye health concern to discuss.
I need to follow up on a previous eye health concern.
I need an updated glasses prescription.
I would like to try contacts for the first time.
None of the above apply, I am seeking preventative care only.
Please note: New wearer contact lens fittings are $100, which includes a mandatory follow-up visit.
I am generally available for this appointment (check all that apply)
Tuesday
Wednesday
Thursday
Friday
Saturday
The following times of day are preferred:( check all that apply)
Morning
Midday
Afternoon
Evening
Submit
Should be Empty: