Book Appointment With Sample Scheduler

Select Location

Select Service & Provider

Select Service

New Patient - Comprehensive Exam

Established Patient - Comprehensive Exam

New Patient - Contact Lens Exam

Established Patient - Contact Lens Exam

Medical Office Visit

Eyewear Pick Up

Eyewear Fitting

Specialty Exam

Select Provider

This area can be fully customized to convey information patients would need to know while scheduling.

HTML coding can be used to make text stand out more. You can make font Bold, different colors, BIGGER, etc.

For Example: If you do not see an available appointment, please call our office at XXX-XXX-XXXX.

Select Appointment Time

This area can be fully customized to convey information patients would need to know while scheduling.

HTML coding can be used to make text stand out more. You can make font Bold, different colors, BIGGER, etc.

For Example: If you do not see an available appointment, please call our office at XXX-XXX-XXXX.

Fill In Your Information

Fields marked with * are required

First Name * Full First Name - No Nicknames or Spaces

Last Name *

Date of Birth * MM/DD/YYYY

/ /

Mobile Number * Start with area code

- -

Email * Confirmation and Pre-Exam instructions will be sent here

Address

City

State

Zip Code

Notes/Concerns

**This area can be customized to convey important information to the patient regarding insurances.**

All insurances listed below can also be customized, as well as, the required fields for each insurance. Customization also includes the ability to separate the insurances by Medical vs. Vision (as seen in the example below). If you only accept one type of insurance, you have the option to only display one dropdown, instead of two separate drop down options.

None / Private Pay

*

Add in custom Terms and Conditions, Privacy, and/or Office Policy message here. Click checkbox to Accept

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