Appointment Request Form

Please fill in the form below to setup an appointment.

What is the appointment for?*

Comprehensive Eye Exam and Eyeglass Prescription
Contact Lens Evaluation - Must Be Current Patient and Current Wearer
Other - please note at the "Comments" section

Please check all that apply. **PLEASE NOTE: If this is an urgent visit, we will not be able to schedule you.

Preferred Date & Time*

First Available

We have limited appointments and may not be able to schedule you.THIS IS NOT A GUARANTEE OF YOUR APPOINTMENT UNTIL OUR STAFF CONTACTS YOU AND CONFIRMS IT BY TEXT OR EMAIL. Please be aware that our reminders are just a courtesy, and it is ultimately the responsibility of the patient/guardian to note the appointment date and time. Please read our APPOINTMENT POLICY on cancellation, rescheduling, and no shows.

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Preferred Date & Times*

Please let us know what day(s) and time(s) you would prefer to have your appointment. THIS IS NOT A GUARANTEE OF YOUR APPOINTMENT UNTIL OUR STAFF CONTACTS YOU AND CONFIRMS IT BY TEXT OR EMAIL. Please be aware that our reminders are just a courtesy, and it is ultimately the responsibility of the patient/guardian to note the appointment date and time. Please read our APPOINTMENT POLICY on cancellation, rescheduling, and no shows.

Patient Type*

New patient
Previous patient

Please let us know if you are a new or existing patient. FOR NEW PATIENTS, in order to be seen at our clinic and confirm the appointment, you must complete the online form BEFORE scheduling.

Patient Name*

First Last

Patient Birthdate*

Address*

Street Address City State ZIP Code

Are you using insurance?*

Yes - WE ARE NO LONGER ACCEPTING INSURANCE
No

WE ARE NO LONGER ACCEPTING INSURANCE FOR NEW OR EXISTING PATIENTS.

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Are you the primary on the insurance?

Yes
No

If you are not the primary on the insurance, please put the name and DOB of the primary in the next box.

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Name and Date of Birth of Primary Insured

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Name of Insurance - PLEASE DO NOT PUT YOUR NAME

You must bring a valid ID and insurance card to your appointment in order to use your insurance. Please call or text our office at 770-917-2221 if you have any questions.

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Insurance Name - WE ARE NOT ACCEPTING INSURANCE FROM NEW PATIENTS

VSP - Vision Service Plan (we cannot schedule unless a valid ID number is given-contact insurance for info if not known)
Spectera or UHC Vision
Davis or Superior Vision (not accepting currently-must self-pay)
Amerigroup (NOTE: We will be providing the exam ONLY; NO glasses will be ordered)
Peachstate - Peachcare (NOTE: We will be providing the exam ONLY; NO glasses will be ordered)

You must bring a valid ID and insurance card to your appointment in order to use your insurance. Please call or text our office at 770-917-2221 if you have any questions.

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Member ID of Insurance

If you do not have the ID, we will not be able to verify, and it will delay the appointment request.

Cell Phone*

Is it okay to text you?*

Yes
No

PLEASE NOTE: Our office is only able to communicate by text or e-mail. Texts are are unencrypted and subject to charges/fees by your carrier that are paid by subscriber. PLEASE REMOVE ANY TEXT BLOCKING OR YOU WILL NOT RECEIVE TEXTS FROM 770-343-5467. Email info@miraeye.com if you have not received a text within 3 business days.

Email*

Is it okay to email you?*

Yes
No

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Best Time to be Reached for Confirmation

:

Comments

PLEASE NOTE! If you do not get a confirmation after pressing submit, please check your email is correct and resend or contact us.

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Appointment NO SHOW or Cancellation/Reschedule Policy*

I have read and understand the appointment policy

Please read our appointment policy and check the box that you have read it. Our reminder system is a courtesy, but you are responsible to notify changes to your schedule.

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Health Policy Agreement*

Yes
No

You are required to read the Health Policy Protocol. FOR NEW PATIENTS, in order to be seen at our clinic, you must complete the online paperwork BEFORE the appointment. Please check Yes or No if you agree to the requirements. If you check No, we will not be able to schedule you for the foreseeable future.

Email

This field is for validation purposes and should be left unchanged.

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770-343-5467 (Text Only)

Appointment Request Form

Douglasville Office Hours & Location

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770-343-5467 (Text Only)

Douglasville Office Hours & Location

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