Tucson Eye Physicians - Appointment Request Form

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 NameLast Name
DATE OF BIRTH (DOB)*

MonthDayYear
Date
PHONE NUMBER*
Please enter a valid phone number.Format: (000) 000-0000.
EMAIL*
example@example.com
CATARACTSDIABETIC EYEGLAUCOMEADULT EYE EXAMPTERYGIUMOTHER
IF OTHER, PLEASE ELABORATE
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URGENT, WITHIN 24 HOURSEMERGENT, WITHIN 36 HOURSROUTINE, WITHIN 4 WEEKS
MORNINGAFTERNOONNO PREFERENCE
WHAT DAY OF THE WEEK WORKS BEST?*
TUCSON: 1745 E SKYLINE DRIVE #175, TUCSON, AZ 85718MARANA: 13395 N MARANA MAIN STREET, MARANA, AZ 85653RIO RICO: 1187 W FRONTAGE ROAD, RIO RICO, AZ 85648SOUTH TUCSON: 231 W AJO WAY, TUCSON, AZ. 85713NO PREFERENCE
DR. KAUFERDR. SWANSONNO PREFERENCE
Should be Empty: