*Patient Name
First and Last Name - As it Appears on Insurance Card

*Email
Make sure this is correct

*Date of Birth
Format: dd-mm-yyyy

*Phone Number
Format: xxx-xxx-xxxx

*Address
Street, Unit Number, City, Zip Code

*Subject
Reason for Email

*Message

Additional Patient(s) Name(s)
(Optional) First and Last Name(s)

Appointment Date
Format: dd-mm-yyyy or Click on the Calendar Icon

Appointment Time 8-10am 10-12pm 1-3pm 3-5pm

Appointment Type Eye Exam Contact Lens Exam Emergency Cataract Evaluation LASIK Consult Second Opinion Other
Select as many as applicable

*Doctor No Preference Dr. Mel Weiss Dr. J. Sean Harper Dr. Paul I. Suji Dr. Steven Bowser
Select Preferred Doctor

Vision InsuranceInsurance Name and ID
For Routine Eye Exam and Eyeglasses/Contact lenses

Medical InsuranceInsurance Name and ID
For Medical Visits

*Required