Appointment Request – McPherson Family Eye Care

* If your vision plan is not listed, please call the office to see if your plan is in network.

First Name*

Last Name*

Phone*

Email*

What is your date of birth?*

Time Requested

Which day(s) of the week do you prefer?

Monday
Tuesday
Wednesday
Thursday
Friday
Saturday

Do you have a doctor preference?

Yes, I do
No, give me first available

Preferred Doctor

New Patient
Existing Patient

What Is Your Vision Plan?

*If your vision plan is not listed, please call the office to see if your plan is in network.

Policy Holder's Name

Policy Holder's Date of Birth

Member ID Number

No-Show & Confirmation Policies*

No-Show Policy: If you cancel your appointment less than 24 hours in advance or if you no-show for your appointment, you will be subject to a rebooking fee of $50.

Confirmation Policy: You must confirm your upcoming appointment. If you do not confirm your appointment within 24 hours of your appointment time, your appointment will be canceled, and it will be offered to a patient on our wait list.

We make it easy to confirm your appointment! You will receive a text message and an e-mail prior to your appointment. You can confirm your appointment through links contained in both of those messages. If we have not heard from you by text or e-mail, you will also receive a phone call.

I AGREE

Email

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