Full Legal Name (First, Last) *

Please indicate your full legal name. Remember during your appointment you may be asked to show ID that corresponds to the full name submitted in this field.

First Name

Last Name

Phone # (ex. 780-955-0786) *

Please indicate the primary phone number that we may reach you at to confirm your appointment

(###)

###

####

Type of Appointment *

Please indicate your appointment type below and if you plan on purchasing eye-wear. Please refer to our services section on our website for detailed descriptions on each type of eye exam. This information helps us determine how long to schedule your appointment for.

Purchasing Glasses (Lens & Frames)

Purchasing Sun Glasses

Contact Lens Fitting

Contact Lens Purchase

Comprehensive Eye Exam

LASIK or Surgery Consultation and Co-Management

Medical + Emergency Eye Care

Work Safety Eye Exam

Eye See - Eye Learn Program (For Children)

Date Requested *

Please fill out the date you would like to request your appointment. Please refer to our hours of operation below to find suitable date when requesting an appointment. Our hours of operation are Monday - Tuesday: 11am to 6pm | Wednesday - Friday: 10am to 5pm | Saturday: 10am to 2pm | Sunday: Closed

MM

DD

YYYY

Health insurance covereage for vision? *

Please indicate if you have insurance coverage for your vision? (we can do direct billing with most providers)

Yes

No

Gender *

Male

Female

Other/Prefer not to mention

First Time Appointment? *

Please indicate if this is your first appointment at True Vision Family Eye Center.

Yes, this is my first appointment

No, I have had an appointment before