Appointment Request Form:  East York Office                                     

 

For eye emergency's please call us or go directly to the nearest emergency room.

 

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
   
Please enter the insurance information below for the subscriber of your policy. The subscriber is the primary person listed on the policy. If the subscriber is your spouse/parent, please enter their information below.
    
Vision Insurance Co:  
Subscribers ID #
  
Policy #                    
   
Group #                   
Subscribers Name           
    
Subscribers SS #
Subscribers DOB

Subscribers Employer

Appointment Request:

Choose a date at least 7-10 business days from today's date.  

Please allow 3-5 weeks for evening and Saturday appointment times.

 

 

    * 

 

 

Reason For Request:  Check all that apply 

 Exam

 Glasses Contacts Lasik Consult

 

 

                                                                     

Please press submit only once. Someone will contact you within 1-2 business days to confirm your appointment. Please make sure you have included your email address and telephone # before submitting. Thank you!

 

 Comments or Special Instructions: