Appointment Form – Michael Alexander

Request an Appointment

Reason For Appointment *

Preferred Time *

Preferred Date *

Patient Type *

Please let us know if you are a new or existing patient.

Vision Plan? *

Name *

First

Last

Date of Birth *

Phone *

Email *

Home Address *

Address Line 1

Address Line 2

City

State

Zip Code

Best Time to be Reached for Confirmation *

Comments

By submitting this appointment request, you acknowledge that Michael Alexander Optical Boutique complies with all applicable HIPAA privacy and security regulations to protect your personal health information. Appointment requests are subject to availability and confirmation. While we participate with select vision plans, submission of this form does not guarantee that your vision or medical insurance is accepted or that benefits are available. Coverage, eligibility, and benefits are verified at the time of your visit. We reserve the right to accept or decline participation with any vision or medical plan and to determine the appropriate fees for services rendered. By requesting an appointment, you agree to these terms and conditions.