Schedule an appointment appointment If you are human, leave this field blank. First Name * Last Name * Email Address * Phone * Date of Birth * Date isn't valid. (eg. mm/dd/yyyy) Phone Type * Home Cell Work I would like my confirmation by: * Email Text Preferred Appointment Day * No Preference Monday Tuesday Wednesday Thursday Friday Preferred Appointment Time * No Preference Morning Afternoon Please indicate below the purpose for your visit (check all that apply): * Eye Glass Examination Contact Lens Examination Laser Vision Correction Consultation/PreOP Medical Office Visit Scheduled Checkup/Followup General Consultation (Other) Insurance Carrier (if applicable) * Not Covered (Self Pay) AARP Advicare Aetna Aetna Vision America’s 1st Choice Medicare America’s Health Plan Blue Choice Blue Choice EPO (exchange) Blue Choice Medicaid Blue Cross EPO (Exchange) Blue Cross Essentials Blue Cross of NC Blue Cross of SC Blue Cross (outside of the Carolinas) Blueview Vision Blue Cross Federal Care Improvement Plus CCN (Choice Care Network) Cigna Consumers Choice Health Plan Coventry Health Plan Community Eyecare EyeMed Eyemed Access Eyemed Insight Eyemed Select First Choice First Health Network Great West Healthcare Humana Instil Health March Vision Care Medcost Medicaid Medicare Meritain Health Molina Healthcare Multiplan Opticare Other Insurance Not Listed Primary Physician Care State Health Plan Superior Vision United Healthcare United Healthcare Medicare United Medical Resources (UMR) Vision Care Plan (VCP) Vision Service Plan (VSP) Wellcare Wellpath Additional Information or Questions Number *Indicates Required Field
