APPOINTMENTS

Appointment Request Form
Please use the following form to request an appointment time. Our scheduling coordinator will contact you to confirm your appointment.
First Name*
Last Name*
Date of Birth (mm/dd/yyyy)*
Street Address*
City*
State*
Zip Code*
Phone*
Email*
Are you a...?*
 New Patient Existing Patient at Roscoe Existing Patient at Southport
Do you wear ...?
 Contacts Glasses Both
Vision Plan
Vision Plan Name*
ID Number
Primary Member’s Name
Primary Member’s Date of Birth (mm/dd/yyyy)
Patient Relationship to Primary Member
NOTE: The ID number may be the primary member’s social security number, so in order to verify your vision benefits we may need the primary member’s social security number.
Insurance Information - If you have a Vision Plan, this information is not neccessary.
Major Medical*
ID Number
Group Number
NOTE: Much like dental coverage, your vision coverage is often contracted out through another company. Your HR department can tell you if the vision is billed directly to your major medical carrier or a vision carrier.
Preferred Appointment Time
STORE HOURS
RoscoeMonday - Thursday
11:00am - 7:00pm
Friday - Saturday
9:00am - 5:00pm
SouthportMonday - Thursday
11:00am - 8:00pm
Friday - Saturday
9:00am - 6:00pm
Sunday
12:00pm - 4:00pm
Location
 Roscoe Southport


Day
 Mon Tue Wed Thurs Fri Sat Sun

Time
 Morning Noon Afternoon Evening
Questions or Comments:

* Required