Eye Exam Appointment Request

Name*

First Last

Phone Number*

Email Address*

Please select an option below.*

New Patient - Never Been at This Office
Established Patient

What are you coming in for?*

Please click on the field and select all that apply.

How did you hear about us?*

My Insurance List
Google Search
Social Media
Friends & Family
Doctor Referral

Gender*

Date of Birth*

Home Address*

Street Address Address Line 2 City State ZIP Code

Hidden

How did you hear about us?

Insurance Information

Are you planning on using insurance for this visit?*

Yes
No

Are you planning on using insurance for this visit?*

Yes
No

Has your insurance changed since your last visit?*

Yes
No

Are you the primary insured on this plan?*

Yes
No

Primary Insured*

First Last

Relationship to Primary Insured.*

Date of Birth*

Date of birth of the primary insured person

Primary Insured Full SSN*

Please enter the social security number associated with the primary insured person

Please enter a number from 0 to 999999999.

Hidden

Vision Insurance Plan*

What is the name of your Vision insurance plan? Ex. VSP, Eyemed, Spectera. If you do not have medical insurance, please type "NA" in this field.

0 of 450 max characters

Vision Insurance Plan*

What is the name of your Vision insurance plan? Ex. VSP, Eyemed, Spectera. If you do not have medical insurance, please type "NA" in this field.

0 of 80 max characters

New Vision Insurance Plan*

What is the name of your Vision insurance plan? Ex. VSP, Eyemed, Spectera. If you do not have medical insurance, please type "NA" in this field.

0 of 80 max characters

Vision Insurance Member ID*

If the member ID is the SSN, please enter SSN here.

0 of 80 max characters

New Vision Insurance Member ID*

If the member ID is the SSN, please enter SSN here.

0 of 80 max characters

Hidden

Medical Insurance Plan*

What is the name of your Vision insurance plan? Ex. BCBS, United Health Care, Aetna. If you do not have medical insurance, please type "NA" in this field.

0 of 450 max characters

Medical Insurance Plan*

What is the name of your Vision insurance plan? Ex. BCBS, United Health Care, Aetna. If you do not have medical insurance, please type "NA" in this field.

0 of 80 max characters

New Medical Insurance Plan*

What is the name of your Vision insurance plan? Ex. BCBS, United Health Care, Aetna. If you do not have medical insurance, please type "NA" in this field.

0 of 80 max characters

New Medical Insurance Member ID*

0 of 80 max characters

Medical Insurance Member ID*

0 of 80 max characters

Other Insurance Plan (Optional)

What is the name of your other insurance plan and member ID, if applicable.

0 of 450 max characters

Insurance & HSA/FSA Card(s) Copy

Please upload a front and back copy of all your insurance cards below. If you have an FSA/HSA card, please upload front & back copy as well. If you're unable to upload the images to this form, please email the copies to info@drlaurettajustin.com.

Drop files here or

Max. file size: 64 MB.

Hidden

Pharmacy Information

For your file, please enter your pharmacy name, phone number, and address below.

Contacts or Glasses Wearer

Do you currently wear contact lenses?*

Yes
No

Are you planning to get evaluated for contact lenses during your visit?*

Yes
No

Do you currently wear glasses?*

Yes
No

Appointment Details

Hidden

To help us better serve you, what is the main reason you're requesting this appointment?*

Hidden

To help us better serve you, what is the main reason you're requesting this appointment?*

0 of 600 max characters

Time Options

What is your preferred time range for an appointment?

Morning Times between 9 am to 12 noon
Midday Hours between 11 am to 2 pm
Afternoon between 2 pm to 5 pm

First Choice*

Second Choice*

Third Choice*

Consent*

I agree to the privacy policy.

I consent that the Company can provide their services and communicate with me via mobile phone, messages, e-mail, and any kind of online communications, provided that these communications comply with privacy regulations.

Appointment Reminders, Reschedules, and Cancellations

I understand that Company can reach me any time to remind me of my appointments or let me know in case of any change about my appointments. And I also understand that the Company can employ and use a third-party automated system to reach out to me for the purpose of "confirm", "reschedule" or "cancel".

Telemedicine Appointments

For telemedicine, I understand the appointments will be held via electronic environments.

Contact Information Change

I accept that I am responsible for notifying the Company when my contact information change.

Consent Cancellations

I know that I can revoke this consent at any time by contacting the Company.

I consent to the use of mobile phone communications.

I consent to the use of texting (messages) communications.

I consent to receive electronic notifications for confirming, rescheduling, or canceling my appointments.

I sign this consent form on the behalf of

Myself/My family/Someone as a legal guardian

Insurance Information

Contacts or Glasses Wearer

Appointment Details

Time Options

Quick Links

Our Office Hours

Contacts

Search

Newsletter – Signup