Appointments | Midland EyeCare

Please use this form for general information purposes only. DO NOT send personal health information through this form. Specific patient care must be addressed during your appointment.

Please complete the following form to request an appointment. Please also note that availability will vary depending on your request. Your appointment will be confirmed by phone by a member of our staff. Thank you!
Name*
Phone*
Email*
Best Time to be Reached for Confirmation*

: Hours

Minutes

AM/PM
Patient Type*
- New
- Returning
- Eye Health Emergency
Preferred Date*
MM slash DD slash YYYY
Preferred Time
Nature of Visit & Age of Patient*
Email
This field is for validation purposes and should be left unchanged.

Please bring your health card and a list of your current medications.

If you are a new patient, please bring the completed “Vision and Health History Form” and your glasses. If you are interested in contact lenses, please let us know when the appointment is scheduled. Sunglasses may be helpful if you are dilated.

If you are unable to attend a scheduled appointment, please give at least a 48-hour notice.