Appointment Request Form: Vision Therapy Associates                       

 

1.  Please fill out the following form. 
2.  Submit your appointment request. 
3.  We will contact you by e-mail or phone to confirm your appointment request.
4. * Required fields 
Current patients need only fill out this form if information has changed.
Name:          *   Date of Birth: *
Address:        * Sex:              Male    Female * 
City:                *    Zip:               *
E-mail:             * First Visit?    Yes    No *
Home Phone: * Work Phone:  *
Phone number for appointment confirmation.*
How did you find out about us?                    
If referred, who may we thank?                    
Employer:         Occupation:

 

Please fill out only if using insurance for this appointment.

 

Vision Insurance Information:*   

Do you have vision insurance? Yes   No 
Vision Insurance Co:
   
Subscribers ID #                 
Policy  #  
    
Group #    
 
Patient SS # 
     
Primary Insured SS #

Appointment Request:

Choose a date at least 2- 3 days from today's date.  

Please allow 2-3 weeks for evening and Saturday appointment times.

 

    * 

 

 

Reason For Request:  Check all that apply 

Vision Therapy

 Other  

 

To help our office better serve your specific needs, please check all that apply.  Please leave blank for a NO answer.
Filling out this form online will help us assist you more promptly during your visit.  If you prefer, however, you may complete it in our office.  This information is confidential and will not be shared with any other source without your written permission.  All information is entered directly into a secure server for your protection.
 

                                                                 

For eye emergency's go directly to the nearest Emergency Room. 

    

Upon submitting your request, we will call you or send an e-mail to verify that your request is available.  It is very important that we confirm your appointment.  Thank you for your request!

 

 Comments or Special Instructions: