Confirm Appointment

First Name:
Last Name:
Birthdate: Example: 05/08/1963
Appointment Date:
Appointment Time:
Do you have a personal history of diabetes?
YES NO
Other Comments:

Submission of this form will confirm your appointment. Please remember to bring all current glasses and contact lens information. Also, bring both your medical and vision insurance cards.

Because Diabetes is the leading cause of blindness, all diabetic patients will be dilated. If you have diabetes, please bring a driver. Remember, dilating the eyes may also affect reading and computer vision for up to 5 hours. We do provide reversal medication to quicken the recovery.

Our Medical History form is now available online. This secure encrypted service will save you time at your upcoming visit. You will be provided a link to the Medical History form after clicking the "Confirm Appointment" button below.