Eye Exam Appointment Request (HSD)

1
Are you requesting a single appointment or multiple appointments?* This field is required.
Single appointment
Multiple appointments
2
How many appointments would you like to request?* This field is required.Max. of 4 appointment requests
2
3
4
3
Who will we have the pleasure to serve?* This field is required.
First Name
Last Name
4
Date of Birth* This field is required.
Date
Month
Day
Year
5
Who else will we have the pleasure to serve? (2nd appointment)* This field is required.
First Name
Last Name
6
Date of Birth (2nd appointment)* This field is required.
Date
Month
Day
Year
7
Who else will we have the pleasure to serve? (3rd appointment)* This field is required.
First Name
Last Name
8
Date of Birth (3rd appointment)* This field is required.
Date
Month
Day
Year
9
Who else will we have the pleasure to serve? (4th appointment)* This field is required.
First Name
Last Name
10
Date of Birth (4th appointment)* This field is required.
Date
Month
Day
Year
11
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
12
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.
13
Address* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
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
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
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
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
14
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.
15
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.
16
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
17
Do you have vision or medical insurance?* This field is required.
YESNO
18
Do you have your insurance card or information with you?
YESNO
19
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.
20
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
21
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
22
Insurance Name* This field is required.
23
Policy Number* This field is required.
24
Referrer
Should be Empty: