A comprehensive exam may take up to two hours.
Please allow adequate time in your schedule. Dilating drops are used and may temporarily blur your vision, and may cause sensitivity to sunlight. We strongly recommend you do not drive immediately after your pupils have been dilated. We suggest you bring a driver if at all possible.
Please bring your glasses and a complete list of the medications you take regularly. This is important for a complete medical history.
The Eye Clinic is offering this "Schedule an Appointment" form for people who don't have time during our regular business hours to call in and schedule an appointment. Please fill out all the information below and press the submit button once.
Your appointment won't be officially scheduled until a representative from our office either emails or calls you to confirm your appointment.
Patient Information
First Name
Last Name
Day-Time Phone
Email Address
Address
Apt #
City
State & ZIP
Date of Birth
month
day
year
Have you been to the Eye Clinic Before
yes
no
If this is your first visit, how did you hear about us?
Internet
Family/Friend
Physician Referral
Advertisement
Phone Book
Other
If you have, how long has it been since your last visit?
in the past month
in the last 6 months
in the last year
more then a year
I don't remember
Reason for Appointment
Is this a routine eye exam?
yes
no
What (if any) specific problems are you experiencing?
Do you wear contact lenses?
yes
no
Scheduling Information
What
days
are convenient for you?
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday (am)
2nd Choice
What
Times
are convenient for you?
Which Doctor would you like to schedule with?
Richard L. Fuller, D.O.
Steven E. Hansen, O.D.
Joseph L. Nemeth, O.D.
Brian E. Wind, D.O.
Michael G. Wood, D.O.
Any Available
Which Office do you prefer ?
3545 Lincoln Way East
830 Amherst RD NE Suite 204
Choose Office Location
How would you like us to confirm your appointment ?
Email
Day time phone
Insurance
As soon as you are able, please have your vision and medical Insurance information available.
We will ask for this when we contact you.
Privacy Policy: The information you supply via this appointment form is considered strictly confidential and will never willingly be shared with anyone without your explicit permission. Some people are concerned about information on the Internet being “hijacked” by hackers. This concern may be valid not only for the Internet, but for any communications by any method, be it wireless telephone, a cell phone, a FAX machine or any other communications device. Although this web page is protected by 128 bit encryption security, The Eye Clinic, Inc cannot guarantee the security of the information you submit using this form as it pertains to electronic transmittal. If you deem the information we ask for to be sensitive, the only way to ensure its absolute security is to discuss it with the doctor face-to-face. We encourage you to do so by requesting an appointment by phone.
I have read and
accept
the privacy policy
© 2006, the Eye Clinic, Inc.
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