Schedule An Appointment

Section Links

> Forms for Clinic Patients

> Forms for Surgery Patients

> Contact Us Online

> Schedule An Appointment

> Contact Information

> Insurance Plans

> What is Refraction?

> Medical vs. Vision Insurance

Schedule an Appointment

Please complete to email an appointment request to our office. Our appointment coordinator will contact you with appointment date and time.

For immediate assistance for an eye emergency or problem, you should call our office at (404) 292-2500. Do not use this electronic request for an immediate appointment due to an eye emergency or problem.

Preferred Appointment Date:
AM or PM:
First Name:
Middle Initial:
Last Name:
Suffix:
Email:
Date of Birth:
Home Phone:
Alternate Phone:
Choose A Doctor:
Do You Have Insurance?
If Yes, Insurance Company:
Location:
New Patient?
If you are a new patient, please complete the following:
Home Address:
City:
State:
ZIP Code:
How Did You Hear About US:

Notice: The message sent with this form is not considered secure. It sends an email to the recipient. Do not send confidential information or anything you would be uncomfortable sending by email.