Appointment Request Form

Please fill in the form below to setup an appointment.

Required questions are marked with a red asterisk (*) and must be completed before submitting the form.

Patient Type*

New patient

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

Name:*
First Last

Address:*
Street Address Address Line 2 City State ZIP Code

Email:*

Phone:*

Patients Date of Birth:*
MM slash DD slash YYYY

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

Requested Doctor:*

Preferred Date & Times:*
Please let us know when you would prefer to have your appointment. Our hours are listed on our location page.

Medical Insurance Company Name*

Policy Holder Name:*
First Last

Member ID:*

Please enter the policy number or member ID for medical insurance.

Insured's Date of Birth:*
MM slash DD slash YYYY

Vision Insurance Company Name*

Policy Holder Name:*
First Last

Policy Number:*

Please enter the policy number or member ID for vision insurance.

Insured's Date of Birth:*
MM slash DD slash YYYY

Comments

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

Miller Family Eyecare