Video Presentation
SCHEDULE AN APPOINTMENT
Please be sure and fill out all Required fields otherwise your request will not be processed. Also we recommend that you fill out as many of the optional fields as possible in order to help us quickly process your request.
Contact Information:
First Name (Required)
Last Name (Required)
Address Line 1
Address Line 2
City
State
Zip
Phone Number (Required)
Email Address
Personal Information:
Date of birth
Sex
Male Female
Employer
Medical Information:
Are you currently wearing glasses or contact lenses?
Yes No
Have you ever had corrective eye surgery such as LASIK?
Referring Doctor
Type of insurance
Emergency Contact Name
Emergency Contact Phone
Reason for visit
Appointment Information:
Are you an existing Assil Eye patient?
Which day(s) of the week are best for you?(Check all that apply)
Monday Tuesday Wednesday Thursday Friday
Which time of the day is best for you?(Check all that apply)
Day Evenings
Additional Comments:
How did you hear about Assil Eye?
Is there anything we can do to improve our service?(Please describe)
Additional Information
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