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 AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific 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:*>>Select>>No PreferenceEllen Miller O.D.Samer Arafat, O.D.Molly Camerer, O.D.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 InformationMedical 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 InformationVision 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 CommentsHiddensource_medium CommentsThis field is for validation purposes and should be left unchanged.
