Come to Millennium Eye Center for caring vision solutions that will enhance your life.
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PREVIEW – Appointment Form 2021
Name
*
First
Last
Phone Number
*
Email Address
*
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
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
Hidden
How did you hear about us?
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
.
Hidden
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 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.
Hidden
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.
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: 64 MB.
Hidden
Pharmacy Information
For your file, please enter your pharmacy name, phone number, and address below.
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
Hidden
To help us better serve you, what is the main reason you're requesting this appointment?
*
Hidden
To help us better serve you, what is the main reason you're requesting this appointment?
*
Time Options
What is your preferred time range for an appointment?
Morning Times between 9 am to 12 noon
Midday Hours between 11 am to 2 pm
Afternoon between 2 pm to 5 pm
First Choice
*
Morning
Midday
Afternoon
Second Choice
*
Morning
Midday
Afternoon
Third Choice
*
Morning
Midday
Afternoon
Consent
*
I agree to the privacy policy.
I consent that the Company can provide their services and communicate with me via mobile phone, messages, e-mail, and any kind of online communications, provided that these communications comply with privacy regulations.
Appointment Reminders, Reschedules, and Cancellations
I understand that Company can reach me any time to remind me of my appointments or let me know in case of any change about my appointments. And I also understand that the Company can employ and use a third-party automated system to reach out to me for the purpose of "confirm", "reschedule" or "cancel".
Telemedicine Appointments
For telemedicine, I understand the appointments will be held via electronic environments.
Contact Information Change
I accept that I am responsible for notifying the Company when my contact information change.
Consent Cancellations
I know that I can revoke this consent at any time by contacting the Company.
I consent to the use of mobile phone communications.
I consent to the use of texting (messages) communications.
I consent to receive electronic notifications for confirming, rescheduling, or canceling my appointments.
I sign this consent form on the behalf of
Myself/My family/Someone as a legal guardian
Δ
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