Come to Millennium Eye Center for caring vision solutions that will enhance your life.
Like Us On Social Media:
Home
About
The Team
Vision For Tomorrow Scholarship
Giving Back
Referrals
Services
Eye Exam
Eyeglasses
Contact Lenses
Myopia Control Clear Vision Program
Low Vision Therapy
Integrative Eye Care
Keratoconus and Other Corneal Diseases Integrative Care
Digital Eye Health
Appointments
Pay My Bill
Patient Resources
Payment Plans
Insurances We Accept
Reviews
Order Contacts
Eye Exam Appointment Request Form
Patient Check-In Form
Custom Frame Orders
Neurolens Survey
Health History for Integrative Eye Care Consult
Other Patient Forms
Patient Medical Record Request
FAQ’s
Blog
Contact
Patient Portal
Eye Exam Appointment Request
Exam Appointment Request
"
*
" indicates required fields
Name
*
First
Last
Phone Number
*
Consent
*
I agree to receive SMS text messages from Millennium Eye Center for appointment reminders, marketing, and general communication. Msg frequency varies. Msg & data rates may apply. Reply STOP to opt out or HELP for support. I have read and agree to the
Privacy Policy
and
Terms & Conditions
.
Email Address
*
Notes/Reminders
Please enter any pertinent notes below regarding your upcoming appointment.
Please select an option below.
*
New Patient - Never Been at This Office
Established Patient
What are you coming in for?
*
Please click on the field and select all that apply.
Eye Exam for Glasses
Eye Exam for Contact Lenses
Keratoconus Consult
Myopia Control Consult
Dry Eye Evaluation
Diabetic Eye Exam
Cataract Eye Exam
Glaucoma Eye Exam
Macular Degeneration Exam
How did you hear about us?
*
My Insurance List
Google Search
Social Media
Friends & Family
Doctor Referral
Other
Gender
*
Female
Male
Non-Binary
Prefer to not disclosed
Date of Birth
*
MM slash DD slash YYYY
Home Address
*
Street Address
Address Line 2
City
State
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
ZIP Code
Insurance Information
Are you planning on using insurance for this visit?
*
Yes
No
Are you planning on using insurance for this visit?
*
Yes
No
Has your insurance changed since your last visit?
*
Yes
No
Are you the primary insured on this plan?
*
Yes
No
Primary Insured
*
First
Last
Relationship to Primary Insured.
*
Date of Birth
*
Date of birth of the primary insured person
MM slash DD slash YYYY
Primary Insured Full SSN
*
Please enter the social security number associated with the primary insured person
Please enter a number from
0
to
999999999
.
Vision Insurance Plan
*
What is the name of your Vision insurance plan? Ex. VSP, Eyemed, Spectera. If you do not have medical insurance, please type "NA" in this field.
New Vision Insurance Plan
*
What is the name of your Vision insurance plan? Ex. VSP, Eyemed, Spectera. If you do not have medical insurance, please type "NA" in this field.
Vision Insurance Member ID
*
If the member ID is the SSN, please enter SSN here.
New Vision Insurance Member ID
*
If the member ID is the SSN, please enter SSN here.
Medical Insurance Plan
*
What is the name of your Vision insurance plan? Ex. BCBS, United Health Care, Aetna. If you do not have medical insurance, please type "NA" in this field.
New Medical Insurance Plan
*
What is the name of your Vision insurance plan? Ex. BCBS, United Health Care, Aetna. If you do not have medical insurance, please type "NA" in this field.
New Medical Insurance Member ID
*
Medical Insurance Member ID
*
Other Insurance Plan (Optional)
What is the name of your other insurance plan and member ID, if applicable.
Insurance & HSA/FSA Card(s) Copy
Please upload a front and back copy of all your insurance cards below. If you have an FSA/HSA card, please upload front & back copy as well. If you're unable to upload the images to this form, please email the copies to info@drlaurettajustin.com.
Drop files here or
Select files
Max. file size: 256 MB.
Contacts or Glasses Wearer
Do you currently wear contact lenses?
*
Yes
No
Are you planning to get evaluated for contact lenses during your visit?
*
Yes
No
Do you currently wear glasses?
*
Yes
No
Appointment Details
Please select your desired appointment time range below. Our team will contact you to finalize your appointment time.
First Choice
*
Morning: 10:00 am - 12:00 pm
Midday: 12:00 pm - 2:00 pm
Afternoon: 2:00 pm - 4: 00 pm
Second Choice
*
Morning: 10:00 am - 12:00 pm
Midday: 12:00 pm - 2:00 pm
Afternoon: 2:00 pm - 4: 00 pm
Third Choice
*
Morning: 10:00 am - 12:00 pm
Midday: 12:00 pm - 2:00 pm
Afternoon: 2:00 pm - 4: 00 pm
Δ
Menu
Translate »
