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Conveniently located at the southwest corner of William Cannon & Mopac

Home » Contact Us » Appointment Request Form

Appointment Request Form

If this is an emergency, do not contact us via email, please use our emergency
contact information

If you have vision insurance: Please include insurance carrier, group number, ID number and patient's DOB in the comment section.  This will allow us to verify insurance benefits prior to your appointment. 

  • Please fill in the form below to setup an appointment.
  • Please provide a reason for your appointment. Details are stored securely and not sent by email.
  • Please let us know when you would prefer to have your appointment. Our hours are listed on our location page.
    Please let us know if you are a new or existing patient.
  • MM slash DD slash YYYY
    Please add your date of birth.
  • Insurance must be verified before appointment is scheduled. Please provide MEDICAL and VISION insurance including Insurance company, Insurance ID#, & name of primary on plan. If you have VSP or Cigna Vision, we will also need the primary’s date of birth and last 4 digits of SSAN.
  • MM slash DD slash YYYY
  • This field is for validation purposes and should be left unchanged.