Request An Appointment Request an Eye AppointmentA member of our scheduling team will review your request and contact you with an available appointment that best matches your preferences.Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.Patient NameFirstLastDate of BirthPhone NumberEmailWhat Medical Insurance do you have?What Vision Insurance do you have?Are you a NEW or ESTABLISHED patient?NEW patientESTABLISHED patientIf you are a NEW patient, please include your address.Appointment Type (non-urgent appointments)Routine Vision Exam (No Medical Diagnoses)Routine Vision Exam + Contact Lens Exam (No Medical Diagnoses)Medical ExaminationIf requesting a Medical Examination, what is the reason for your appointment? If requesting a Contact Lens appointment, are you NEW to contact lens wear?Yes, I am NEW to contact lens wearNo, I am already familiar and established with contact lens wearPreferred location:Burlington LocationMebane LocationFirst Available LocationOptometrist for Routine Vision Exam and Contact Lens ExamGeorge Katsoudas OD (Bur: M, T, W, F) (Meb: Th) what you and Preferred doctor for Medical Examination (Ophthalmologists)Any OphthalmologistSteven Dingeldein MD (Bur: M, T, W)Chadwick Brasington MD (Bur: M, T, Th, F)William Porfilio MD (Bur: M, W, Th, F)Bradley King MD (Bur: W, Th) (Meb: T, F)Anthony Fiacco MD (Bur: M, T, F) (Meb: W)Mark Shapiro MD (Bur: W, Th)Preferred Appointment Day(s)Any DayMondayTuesdayWednesdayThursdayFridayPreferred Appointment Time(s)Any TimeMorningAfternoonAdditional details for non-urgent appointmentsInterpreter Needed?NoSpanishSign LanguageOther*SUBMIT* (Please note: submitting this form does not schedule or confirm an appointment. If you have an urgent concern, please call our office directly. If this is a medical emergency, call 911.)
