Request An Appointment

If this is an Emergency, please contact us or your local urgent care/emergency hospital immediately.

FVC27Please bring your glasses, prescription sunglasses and if you’re a contact lens wearer, your contact lens boxes, with you to your appointment.
Please add new or any changes to Medical and Vision Insurance information to the Comments section on your Appointment Request*:

Insurance Name
Primary/Subscriber’s Name and Date of Birth
Patient’s Date of Birth
Medical Insurance: Insurance ID Number and Group Number
VSP Vision Insurance: Last 4 Digits of Primary/Subscriber’s Social Security Number

***Without accurate insurance information at least one business day in advance (of your scheduled appointment), we can not guarantee we will be able to verify the eligibility of insurance benefits with your insurance company . If we are unable to verify insurance eligibility prior to your appointment, you will be responsible for any charges.

Patient Information

First Name (required)

Last Name (required)

Date of Birth (required)

Phone Number (required)

Email (required)

Address1 (required)

Address2

City (required)

State(required)

Zipcode

Contact Information (If you are making appointment for the patient)

First Name

Last Name

Phone Number

Email

Contact Method

Preferred Contact Method: PhoneEmail

Appointment Information

Appointment Type (required):

Preferred Days (required): TuesWedThursFriSat

Preferred Times (required): MorningAfternoonEvening

Have you been to our clinic before? YesNo

If not, how did you hear about us? AdvertisementInsuranceSearch EngineI am/my family is a patientLive NearbyFriend or Family MemberCommunity EventOther

Do you wear contacts? YesNo

Medical Insurance Information (optional)

Medical Insurance:

Policy Holder's Name:

Policy Holder's Date of Birth:

Group #:

ID #:

Vision Insurance Information (optional)

Vision Insurance:

Policy Holder's Name:

Policy Holder's Date of Birth:

Policy Holder's last 4 digits of social security #:


Additional Information or questions you may have:

Please leave this field empty.