Appointment Request Form
PLEASE COMPLETE THIS FORM TO REQUEST AN APPOINTMENT. OUR TEAM WILL CONTACT YOU TO CONFIRM THE APPOINTMENT DETAILS. **PLEASE NOTE THAT AN APPOINTMENT IS NOT SCHEDULED UNLESS IT IS SCHEDULED AND CONFIRMED BY THE PRACTICE.
PATIENT NAME
*
First Name
Last Name
DATE OF BIRTH (DOB)
*
-
Month
-
Day
Year
Date
PHONE NUMBER
*
Please enter a valid phone number.
Format: (000) 000-0000.
EMAIL
*
example@example.com
REASON FOR APPOINTMENT REQUEST
*
CATARACTS
DIABETIC EYE
GLAUCOME
ADULT EYE EXAM
PTERYGIUM
OTHER
IF OTHER, PLEASE ELABORATE
blanks
blank
URGENCY OF VISIT
*
URGENT, WITHIN 24 HOURS
EMERGENT, WITHIN 36 HOURS
ROUTINE, WITHIN 4 WEEKS
WHAT TIME OF DAY WORKS BEST?
*
MORNING
AFTERNOON
NO PREFERENCE
WHAT DAY OF THE WEEK WORKS BEST?
*
Please Select
Monday
Tuesday
Wednesday
Thursday
Friday
DO YOU HAVE A LOCATION PREFERENCE?
*
TUCSON: 1745 E SKYLINE DRIVE #175, TUCSON, AZ 85718
MARANA: 13395 N MARANA MAIN STREET, MARANA, AZ 85653
NOGALES: 1710 N MASTICK WAY NOGALES, AZ 85621
ANKLAM: 1712 W ANKLAM RD #103 TUCSON, AZ 85745
NO PREFERENCE
Doctor Preference
DR. KAUFER
DR. SWANSON
NO PREFERENCE
Submit Appointment Request
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