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 as we work to implement and refine new procedures due to COVID19.
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 need an updated contact lens prescription.
I would like to try contacts for the first time.
I have insurance benefits or Flex $ I need to use before 12/31/2020.
None of the above apply, I am seeking preventative care only.
We strongly recommend pupil dilation or Optos fundus photography to examine the retina; this is an important part of the eye exam. Would you be willing to pay for this option, if clinically appropriate?
Are you planning to shop for glasses as part of this 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: