Schedule Online

Schedule Online

    Contact Information

    First Name (Required)

    Last Name (Required)

    Street


    City



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    Zip Code

    Email Address (Required)

    Date of Birth (Required)

    Phone Number (Required)

    Alternative Phone Number

    Are you a new patient? (Required)

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    How did you hear about us?

    Insurance Information

    Health Insurance Company Name (Required)

    Health Insurance Member ID Number (Required)

    Vision Insurance Company Name (Required)

    Vision Insurance Member ID Number (Required)

    If not applicable, please type none

    Appointment

    Preferred Doctor (Required)

    Type of Appointment (Required)

    Preferred Day (Check all boxes that apply)
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    Preferred Time

    Comments

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    Please note that not all Doctors work every day. We will try to accommodate you to the best of our ability. If you have any questions, feel free to call us at (517) 337 – 8182 or send an email to frontdesk@visioncarepc.com. If we need additional information to fill your request, you will receive a phone call from us.

    Health History Form

    Records Release Form

    HIPAA Notice of Privacy Practices

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