Appointment Request Form:  West 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 
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 

 Exam

 Glasses Contacts Laser Vision

 Other  

 

  No change since Last Eye Exam (go to bottom of page and submit request)

                                                                     

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: