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.
Scheduling Notice:We are nearly fully booked for the year. New appointment requests are currently being scheduled for the end of 2026 or early 2027.If you are experiencing an urgent eye issue, please call our office directly instead of submitting this form.
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
2 digit month, 2 digit day, 4 digit year
Date
Patient's Gender
*
Male
Female
Patient's Preferred Pronouns
He/His/Him
She/Her/Hers
They/Them/Theirs
Other
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
2 digit month, 2 digit day, 4 digit year
Date
Insurance Subscriber's Gender
Male
Female
Do you have separate vision insurance ?
Yes
No
Please select vision insurance plan:
VSP
Eyemed
Other
Vision Insurance Patient ID - for VSP, use the last 4 digits of your SSN.
Back
Next
Please let us know what you hope to accomplish at your visit:
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.
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
Do you need to be seen by year end due to insurance benefit or flex spending timing?
Will the patient be in the area for a limited time?
Earliest date the patient is available:
Latest date patient is available:
Thank you for being patient with us.
We are doing our best to respond to appointment requests as soon as possible, as it is our busiest time of year.If you have an urgent medical eye health concern, we ask that you please contact the office and follow the appropriate prompts. Thank you for choosing us!
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