Cognivue Appointment Request
Please fill out the following fields. If you have any questions, don't hesitate to call us at (918)542-4444.
Personal Information
Name
*
First Name
Middle Name
Last Name
Phone Number
*
Email
If you would like your report sent to your email.
Date of Birth
*
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Month
/
Day
Year
Sex
*
Male
Female
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Please answer the following questions to ensure you are able to take this test.
Are you fluent in the English language?
*
Yes
No
Do you have full vision in at least 1 eye?
*
Yes
No
Do you have full use of at least one hand, including full range of motion?
*
Yes
No
Are you in overall good health, with no major acute symptoms?
*
Yes
No
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Appointment Scheduling
Please let us know if you do not see a time that works for you by calling us at (918)542-4444
Appointment
*
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You may arrive a few minutes before your scheduled appointment time to fill out necessary paperwork.
If you were not able to schedule an appointment, a staff member will be reviewing your information and contacting you at a later date.
Is there anything else we should know before your appointment?
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