You have selected the appointment at:
Wednesday May 01 1:00pm

Enter all issues you have a concern about. Use buttons and/or enter own response:

Eye Pain Dry Eyes Blurry Vision Floaters Headaches Glaucoma Cataract Diabetes Contacts Glasses ERASE ALL

Enter all Medical AND Vision plans you are covered by. Use buttons and/or enter own response:

Medicare Apple BCBS Regence Premera Kaiser Cigna Aetna United HMA Davis VSP First Choice ERASE ALL

First Name:


Last Name:


Ten digit mobile phone:


Confirmation email:


Birthday as MMDDYYYY: