Appointment Request Form Please fill in the form below to setup an appointment.Patient Type* New patient Returning patient Reason for Appointment* Complete Eye Exam (Glasses) Complete Eye Exam (Contact Lenses) Emergency Office Visit (Red Eye, Irritation, Foreign Bodies, etc) Purchase Frames/Lens Other Please select all that apply.Other*Please specify the reason for the appointmentVision Insurance* Yes, I have vision insurance I want to use. No, I am self-pay. Vision Insurance Company*VSPEyemedSuperiorAetna MedicarePlease be advised, not all plans are in network.Primary* Yes No Are you the primary vision plan holder?Primary Name* First Last Please provide the name of the primary plan holder.Primary Date of Birth* MM slash DD slash YYYY Please provide the date of birth of the primary plan holder.Member IDPatient Name* First Last Patient Date of Birth* MM slash DD slash YYYY Phone*Email* Preferred Contact Method* Call Text Message Email Preferred Dates & Times*Please let us know when you would prefer to have your appointment. Our hours are listed on our location page.CommentsEmailThis field is for validation purposes and should be left unchanged. Δ