Appointment Request Form

Please fill in the form below to setup an appointment.
Patient Type*
- New patient
- Returning patient
Please let us know if you are a new or existing patient.
Name*
First Last
Phone*
Email*
Date of Birth*
Month
Day
Year
Reason for Appointment
Please provide a reason for your appointment. Details are stored securely and not sent by email.
Preferred Date & Times*
Please let us know when you would prefer to have your appointment. Our hours are listed on our location page.
Best Time to be Reached for Confirmation*

: Hours

Minutes

AM/PM
Comments
Insurance Information
Please fill out the Vision and Medical Insurance information below, and read the descriptions below to know why we need both types of insurance information and how they're used at our office.
Vision Insurance
Vision insurance is actually a vision benefit, designed to pay toward "routine" comprehensive eye examinations. A "routine" eye examination checks for, but finds no medical problems. The refraction (determination of the eye's prescription) is included, and since there are no medical problems, there is no discussion of problems or follow-up needed. Most vision insurance plans do not pay toward the contact lens portion of the examination, but may offer a discount on these services. Vision insurance plans often pay a portion of (or offer a discount on) eyeglasses or contact lenses.
Medical Insurance
Medical insurance pays toward eye care visits that are medical in nature. An emergency visit, or one focused on a specific eye problem, would be submitted to medical insurance. Some examples of a medical visit are: eye infection, floaters, eyelids styes, dry eyes, glaucoma treatment, loss of vision caused by a medical condition of the eye, etc.

Medical insurance may also pay toward a comprehensive examination if there is a medical reason for it (such as diabetes, cataracts, or any of the previously listed reasons). If there is a medical diagnosis, we are required to submit the examination to the medical, not vision, insurance.
Name of Vision Insurance
Vision Insurance Subscriber ID
Name of Medical Insurance
Medical Insurance Subscriber ID
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Phone
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Insurance Information