Request an eye Appointment with Eye Specialist Doctor of Ohio

REQUEST APPOINTMENT

If this is an emergency, please call our office or the emergency room directly.
Please use this form for non-urgent appointments only.
For same-day appointments, we request that you call our office
directly at the number listed in the LOCATIONS section of our web site.
If you have not heard from us within 48 hours if this appointment,
please call our Office at 800-948-EYES.

I would like to request an appoint with the following Doctor:

Harmeet Chawla, MD - Medical Director
Terry Schultz, OD - Center Director
Kelli Chawla, OD - Clinical Optometrist
Himanshui Joshi, DO - Clinical Ophthalmologist
Phil Dafler, M.D - Clinical Ophthalmologist
Stephen R. Hein, MD - Clinical Ophthalmologist
Patrick D. Schumacher - Clinical Ophthalmologist
Jay S. Egolf, MD - Clinical Ophthalmologist
Stacia Waddle-Wilkins, OD - Clinical Optometrist
Roger Adler, M.D. - Clinical Ophthalmologist

Enter Patient's information below:

First Name:
Last Name:
Address:
Address 2:
City:
State/Province:
Zip/Postal Code:
Country :
Day Phone Number:
Evening Phone Number:
Email Address:
New Patient ?	Yes No

Insurance Information
Enter the information below if you are new to this office or if any insurance information has changed since the last visit.

Insured person's relationship to the patient:	Self Spouse Parent or Guardian Other
Insured First Name:
Insured Last Name:
Plan Name:
Plan Number:
Insured's Member ID:
Group Number:

Appointment Request
You may specify up to 3 appointment choices. If we cannot accommodate your 1st choice, we will try to schedule your 2nd choice, then your 3rd choice. We will confirm your appointment request by the method you select below. Appointments must be at least seven days in advance.

1st Choice:
2nd Choice:
3rd Choice:
Reason for Appointment:
Comments:	Confirm My Appointment By: Email Phone

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