Thank you for choosing Collins Vision!

For your convenience, we offer you the ability to request an appointment online. You can do so by filling out the form below, and our team will make every effort to reach out to you within 24 hours of your request. If you’d prefer to schedule your appointment via phone, our friendly team is happy to assist. Call us at 239.936.4706

    First Name (required)

    Last Name (required)

    Date of Birth (required)

    Phone (required)

    Email (required)

    Your Address

    Address (line 1)

    Address (line 2)

    City

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    Zip Code

    How would you prefer us to reach you? (required)

    Appointment Type (required)
    LASIK ConsultationCataract Surgery ConsultationEyelid Surgery ConsultationGeneral Eye Exam/Glasses/ContactsMedical Eye Exam (Known issue present)Other

    Are you an existing patient? (required)
    YesNo

    Did another doctor refer you to our office?
    YesNo

    If Yes, what is their first and last name?

    How did you hear about us? (required)

    Preferred Office:
    Fort MyersNaples

    Do you prefer mornings or afternoons?

    Medical Insurance:

    Medical Policy Number:

    Vision Insurance:

    Vision Policy Number:

    Additional Information

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    Note: Messages sent using this form are not considered private. Please contact our office by phone if sending highly confidential or private information.

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