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.
Doctor
Reason for Appointment
Please provide a reason for your appointment. Details are stored securely and not sent by email.
Preferred Date & Times*
Please let us know when you would prefer to have your appointment. Our hours are listed on our location page.
Patient Type*
- New patient
- Returning patient
Please let us know if you are a new or existing patient.
Name*
First Last
Date of Birth*
MM slash DD slash YYYY

Please add your date of birth.
Phone*
Email*
Insurance
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.
Date
MM slash DD slash YYYY
Name
This field is for validation purposes and should be left unchanged.