Patient Information

Thank you for choosing Eye Life Vision Center for your comprehensive eye care. To request an appointment with one of our doctors, please fill in the information below.

Patient Type *

New

Returning

Gender *

Female

Male

First Name *

Last Name *

Street Address *

City *

State *

Zip Code *

Phone Number *

Type *

Email Address *

Preferred method of contact *

Birth Date (MM/DD/YYYY) *

Do you plan to use your insurance for this visit? *

Yes

No

Changes to insurance since last visit? *

Yes

No

Medical Insurance *

Insurance number *

Other insurance

Vision Insurance *

Last 4 of SS# (Needed for VSP) *

Unfortunately we do not accept EyeMed,

however you can self submit to EyeMed for reimbursment.

If we receive this during-non business hours, we will get back to you as soon as we can.

Important information

Please be aware that if you have a medical issue with your eyes, a vision plan will NOT cover the exam, and will go through your medical insurance. Vision plans are designed for routine eye exams only. However, your vision plan may still be used to cover your glasses and/or contact lenses.

However, if you do have medical insurance and no vision plan, your medical insurance may still cover the eye exam if you have certain ocular or visual problems.

Date and Time

Office Hours:

Mon: 10:00AM to 5:00PM

Tues: Closed

Wed: 10:00AM to 6:00PM
Thurs: 9:00AM to 5:00PM

Fri: 8:30AM to 2:30PM

Sat: 8:00AM to 2:00PM

Sun: Closed

First Choice: What day of the week works best? *

Time of Day *

Second Choice: What day of the week works best? *

Time of Day *

Or enter a specific date

Appointment Information

Interested in contact lenses? *

Yes, and I want to get a new supply of contact lenses

No, I am NOT interested in contacts at this time

Preferred Doctor

Dr. Julie Sheen

Dr. Richard Sui

Dr. Nicole Roy

No preference

Finally, how did you hear about us?

Internet Search	Referral
Insurance	Social Media ie Facebook, Instagram
Other Other