Eye Exam Appointment Request (Tulsa)

1
Which location will you be visiting?* This field is required.
Tulsa, OK
Sand Springs, OK
2
Are you requesting a single appointment or multiple appointments?* This field is required.
Single appointment
Multiple appointments
3
How many appointments would you like to request?* This field is required.Max. of 4 appointment requests
2
3
4
4
Who will we have the pleasure to serve?* This field is required.
First Name
Last Name
5
Date of Birth* This field is required.
Date
Month
Day
Year
6
Who else will we have the pleasure to serve? (2nd appointment)* This field is required.
First Name
Last Name
7
Date of Birth (2nd appointment)* This field is required.
Date
Month
Day
Year
8
Who else will we have the pleasure to serve? (3rd appointment)* This field is required.
First Name
Last Name
9
Date of Birth (3rd appointment)* This field is required.
Date
Month
Day
Year
10
Who else will we have the pleasure to serve? (4th appointment)* This field is required.
First Name
Last Name
11
Date of Birth (4th appointment)* This field is required.
Date
Month
Day
Year
12
Email* This field is required.The best email to contact you for appointment reminders and updates. ATTENTION: If you are requesting an appointment for a minor or are yourself one, please enter the parent or guardian information below.
example@example.com
13
Phone Number* This field is required.The best phone number to contact you for appointment reminders, additional information request, and updates. ATTENTION: If you are requesting an appointment for a minor or are yourself one, please enter the parent or guardian information below.
Please enter a valid phone number.
14
Address* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
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Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
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El Salvador
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Eritrea
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Ethiopia
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Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
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Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
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Hungary
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India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
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Kenya
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Laos
Latvia
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Lesotho
Liberia
Libya
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Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
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Northern Mariana
Norway
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Palau
Palestine
Panama
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Paraguay
Peru
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Pitcairn Islands
Poland
Portugal
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Russia
Rwanda
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Saint Helena
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South Sudan
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Sudan
Suriname
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eSwatini
Sweden
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Syria
Taiwan
Tajikistan
Tanzania
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Tokelau
Tonga
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Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
15
Preferred Appointment Date/Time (1st option)* This field is required.We will aim to schedule your appointment on your selected date and time. If we are unable to, we will look for a similar date and time. For multiple appointment requests, only a single date and time selection is necessary. Final appointment date and time confirmation will happen through text or phone call.
16
Preferred Appointment Date/Time (2nd option)* This field is required.We will aim to schedule your appointment on your selected date and time. If we are unable to, we will look for a similar date and time. For multiple appointment requests, only a single date and time selection is necessary. Final appointment date and time confirmation will happen through text or phone call.
17
How would you like to be contacted for your appointment confirmation?* This field is required.We will use your preferred methods below to confirm your appointment and to reach out if we need any additional information such as insurance policy.
Phone Call
Text
18
Do you have vision or medical insurance?* This field is required.
YESNO
19
Do you have your insurance card or information with you?
YESNO
20
Please select your preferred way for sharing your insurance information with us so we can check your benefits before your visit:* This field is required.
Upload picture of insurance card (Front & Back)
Type-in insurance provider name and policy number.
21
Upload picture of insurance card (Front)* This field is required.
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
22
Upload picture of insurance card (Back)* This field is required.
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
23
Insurance Name* This field is required.
24
Policy Number* This field is required.
Should be Empty: