Your Name	Your E-mail Address (optional)
Your Daytime Telephone	Your Evening Telephone
Schedule a... LASIK ScreeningPost LASIK Check-up Contact Lens ExamLow Vision ExamRegular Exam General Consultation

Day MondayTuesdayWednesday ThursdayFridaySaturday

Time * MorningAfternoon Evening

Month JanuaryFebruaryMarch AprilMayJuneJuly AugustSeptemberOctober NovemberDecember

Date 1st2nd3rd4th 5th6th7th8th9th 10th11th12th13th 14th15th16th17th 18th19th20th21st 22nd23rd24th25th 26th27th28th29th 30th31st

Year 20052006

* Evening appointments are available Thursdays and Fridays.

Fill out this portion of the form only if you have vision health coverage. If you are not currently covered for vision care, you may skip this section.
Who provides your plan? - No Coverage -Coast to Coast Vision PlanElite Vision Plan "Block Vision" (ECPA) Eye Care Plan of AmericaEyes UnlimitedHMO-Illinois MetLife (BCBS)(NVA) National Vision Administrators Plan Plus "Block Vision"Vision Direct Plan Vision Max (Community Vision Care)Vision One Eyecare (VSP) Vision Service Plan	Your Social Security Number
Is this appointment for a covered individual other than the primary policyholder? YesNo
If so, please provide that person's name and Social Security number.
Name	Social Security Number

You may use the space below to include additional comments or information regarding this Appointment Request.

After you submit your Appointment Request you will receive a telephone call and/or e-mail from us to confirm the date and specific time of your appointment.