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704-348-1500
CLICK HERE FOR OFFICE PROCEDURES CONCERNING COVID-19
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Our Charlotte Practice
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Meet Our Team
Eyewear Boutique
Eye Care Services
Eye Health Evaluation
Contact Lenses
Specialty Contact Lenses
Treatment of Eye Disease
Myopia Control and Pediatric Care
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About
Our Charlotte Practice
Meet Our Doctors
Meet Our Team
Eyewear Boutique
Eye Care Services
Eye Health Evaluation
Contact Lenses
Specialty Contact Lenses
Treatment of Eye Disease
Myopia Control and Pediatric Care
Contact Us
704-348-1500
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Patient Information
First Name
Last Name
Email
Phone
DOB
Gender
Choose One
Female
Male
Other
Vision Insurance
Choose One
VSP
Eyemed
Community Eye Care
Superior Vision
BCBS
Other (please list below)
No Vision Insurance
Other Insurance
Do You Wear Contact Lenses?
Choose One
Yes - Soft contact lenses
Yes - RGP or specialty contact lenses
No, but I would like to be fit in them at my exam
No
Appointment Preferences
Preferred Day (Check any days you're available)
Monday
Tuesday
Wednesday
Thursday
Friday
All Days
Preferred Time (Check all available time frames)
Morning
Afternoon
Anytime
Any Specifics / Information
Communication Consent
I give my permission to send me email and sms communications.
Submit
