MISSED APPOINTMENTS: If you fail to show up for your appointment without rescheduling or canceling twenty four (24) hours prior to your appointment time, there will be up to a $25.00 fee charged to you. Any insurance authorizations will be held until the fee has been paid to our office. In addition, you will not be able to use your insurance benefit for your eye exam at another location.

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  Personal Details

  • First Name:
  • Last Name:
  • Dob:
  • Email:
  • Phone:
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  Appointment details

  • Reason for visit:
  • Insurance provider:
  • Appointment time: