Request An Appointment | Alamance Eye Center

Patient Name

First

Last

Date of Birth

Phone Number

Email

What Medical Insurance do you have?

Additional Appointment (Ophthalmologists)

What Vision Insurance do you have?

Are you a NEW or ESTABLISHED patient?

Appointment Type (non-urgent appointments)

If requesting a Medical Examination, what is the reason for your appointment?

If requesting a Contact Lens appointment, are you NEW to contact lens wear?

Preferred location:

Optometrist for Routine Vision Exam and Contact Lens Exam

Preferred doctor for Medical Examination (Ophthalmologists)

Preferred Appointment Day(s)

Preferred Appointment Time(s)

Additional details for non-urgent appointments