Request An Appointment

REQUEST AN APPOINTMENT

If you would like an appointment with one of our eleven physicians, please fill out the following information and someone will contact you soon. Items with astricks (*) are required information.

Thank you for registering on-line for your Ophthalmology appointment. If there is anything else we can do for you, plese do not hesitate to let us know.

Email:
Phone:

Patient Information

* Patient Name:
* Address:
* City:
* State:
* Zip:
Country:
* Daytime Phone Number:
* Email Address:
Date of Birth:
Gender:
Are you a new patient?	Yes No
If not, who is your physician?

Appointment Preference

Day of the week:
Time of the week:
When:

Primary Insurance

Please bring your insurance card on the date of your appointment

If your insurance information has changed since your last visit, or you are a new patient, please fill out the form below.

Insurance Company:

* Health Insurance Type:
* Insured�s Name:
* Member ID Number:
* Employer Name:
* Group Name:
* Verification / Customer Service Number:
* Treating Physician�s Name:
* Treating Physician�s Phone Number:

If you are requesting an appointment for another person, please tell us how to contact you.

* Your Name:
* Email Address:
* Daytime Phone Number:

Additional Information

Reason for appointment / additional comments:

INSURANCE AUTHORIZATION AND ASSIGNMENT
I hereby authorize my insurance company to pay Jackson Eye Associates PLLC as services are provided. If, for any reason, I have a balance on my account, I agree to pay promptly upon receipt of a statement. I acknowledge and understand I am responsible for all charges for services rendered to me or any member of my family. I authorize release of any information to process my claim.

For general questions about appointment making, refer to our Frequently Asked Questions.

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