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*
- New patient
- Returning patient
Please let us know if you are a new or existing patient.
Name*
First Last
Date of birth*
Phone*
Appointment Communication Preference
- Text Message
- Phone Call
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*

: Hours

Minutes

AM/PM
Name of Vision Insurance
Member ID*

Please provide member ID. It is a separate number from your group number.
Comments
Name
This field is for validation purposes and should be left unchanged.

Waterford Lakes Eye Care