Elliott Eye Associates - Appointment Request

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To request an appointment, complete the following form at least 48 hours before the time requested. A staff member of Elliott Eye Associates will contact you to confirm your time or to select an alternate time. If you need to get in immediately or would like an appointment within 48 hours, please call the office at (972) 393-8600 and we will do what we can to accommodate you. Print our Patient Information Form (New Patients) (Returning Patients), fill it out, and bring it with you the day of your exam.

           New Patient        Existing Patient

Name (Last, First):
Phone (home):
Phone (work/cell):
Email:

Please enter the requested appointment times:
First Choice: @
Second Choice: @

Reason for Visit: Glasses   Contact Lenses   LASIK                               Orthokeratology / CRT    Other

Vision Insurance Carrier?
   If filling insurance, SS#:
                              DOB:

Medical Insurance Carrier?
   Group #:
   Member ID:

How would you like to be notified? Email  Phone(h) Phone(w/c)

Office hours: 8:30am - 5:30pm (Monday & Wednesday)
10:00am - 7:00 pm (Tuesday & Thursday)
9:00am - 1:00 pm (Friday)
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The optomap® ultra-widefield retinal exam is an amazing tool in evaluating the health of the eye and the the retina.
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