First Name:
Last Name:
Email:
Phone:
Medical Eye Exam
Glasses Exam
Contact Lens Exam
Both Glass and Contacts
Lasik Evaluation
Exam Type:
None (Selfpay)
VSP
BCBS
Cigna
Lovelace
Medicare
Presbyterian
Tricare
United Healthcare
Healthsmart
Trustmark
Vision Care Direct
Monday
Tuesday
Wednesday
Thursday
Friday
Insurance:
Preferred Day:
Time Preference:
Before Noon
After 1:00
Anytime
Yes
No
New Patient?
Please call our office at (575) 526-5367, or use the following form to request that one of our
professional staff members contact you to schedule your exam:
Appointment Scheduling: