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 Date of Birth
Contact Person Name ( if different)
Preferred Phone Number
Phone number above is
Mobile - and text messages are OK (preferred)
Mobile - but avoid text messages if possible
Street Address Line 2
State / Province
Postal / Zip Code
Medical Insurance Company - Type "SELF PAY" if none
Medical Insurance Number - Type " SELF PAY" if none
For the insurance above, the patient is:
What is the insurance subscriber's name?
What is the insurance subscriber's Date of Birth?
Do you have separate vision insurance ?
Please select vision insurance plan:
Vision Insurance Patient ID - for VSP, use the last 4 digits of your SSN.
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)
The following times of day are preferred:( check all that apply)
Should be Empty: