Appointment Request

Appointment Request

If submitting your request on a weekend, please allow up to 72 hours for a response. If you need immediate assistance, call or text our office number. 203.265.5152
Name:*

First NameLast Name
Date of Birth:*

MonthDayYear
E-mail:*
Phone Number:*

Area CodePhone Number
Please check this box if the above number is a cell phone & it is okay to receive texts from our office*

Yes, please text the above phone number
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
*Complete insurance information is required prior to booking an appointment.*

Please note that we don't participate with Davis Vision or Spectera.
Vision Insurance*

NoneEyeMedVision Service Plan (VSP)
Vision Insurance Member ID #:
(For VSP, please input the SSN of the primary policy holder)
Medical Insurance:*
If you don't have medical coverage, please type "self pay"
Medical Insurance Member ID #:
Eye Health Issues*

Floaters/FlashersWatering/TearingRed or Bloodshot EyesItchy EyesStyeSwollen Or PuffyCan't See Far AwayCan't See Close UpNone
Doctor Preference:
Appointment Preference:*

Weekday MorningWeekday AfternoonEveningSaturday
Type of appointment (check all that apply)*

New PatientExisting PatientExamOffice Visit / Eye ProblemCurrent Contact Lens WearerInterested In Contact LensesLASIKInterested In LASIK
Message:
Should be Empty:

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