Appointment Request

First Name (required)

Last Name (required)

Date of Birth (required)

Phone (required)

Email (required)

Your Address

Address (line 1)

Address (line 2)

City

State

Zip Code

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

Phone CallText MessageEmail

Appointment Type (required)

LASIK ConsultationCataract Surgery ConsultationEyelid Surgery ConsultationGeneral Eye Exam/Glasses/ContactsMedical Eye Exam (Known issue present)Dry Eye ConsultationOther

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)

—Please choose an option—Already A PatientBillboardCollins Vision EmployeeCVPDoctor ReferralDrive ByEmailEventHospitalInsuranceLocal HeroesMagazineMailerNewspaper – NaplesNewspaper – Fort MyersNextdoor AppOnlineOther WebsitePatient ReferralPGA TournamentRadioRosen- Snead GroupShare the LoveSocial MediaTV Commercial

Preferred Office:

Fort MyersNaples

Do you prefer mornings or afternoons?

—Please choose an option—MorningAfternoon

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.