Appointment Request Form

Please fill in the form below to setup an appointment.

Reason for Appointment

Please provide a reason for your appointment. Details are stored securely and not sent by email.

Patient Type*

Please let us know if you are a new or existing patient.

Name*

First Last

Date of birth*

Phone*

Appointment Communication Preference

Please choose one you tell us how you'd like us to communicate with you to make this appointment.

Address*

Email*

Best Time to be Reached*

:

Name of Vision Insurance

Member ID*

Please provide member ID. It is a separate number from your group number.

Comments

This field is for validation purposes and should be left unchanged.

Waterford Lakes Eye Care