West Georgia Eye Care Appointment Request Form
Please complete as best as you are able. Once you submit this form for a
regular or routine eye exam
our appointment staff will contact you to set up your appointment. (If you have an urgent medical problem, please call the office at 706-323-3491.)
Please be aware that West Georgia Eye Care Center
does not accept vision insurance
. Should you have a medical diagnosis, medical insurance will be filed.
Email Address (will not be used for solicitation)
Date of Birth
Please select todays date.
If you would like, choose your preferred doctor. If you don't have one, simply leave the choice set for any.
Dr. Stephen Beaty
Dr. James Brooks
Dr. Charles Calhoun
Dr. Sterling Cannon
Dr. Bret Crumpton
Dr. Edward Curran
Dr. Nicholas Mayfield
Dr. Cynthia Nix
Dr. Mark Smith
Dr. Charles Speakman
Please tell us what type(s) of service you are requesting for this appointment. (Check all that apply)
Contact Lens Exam
Free LASIK Consultation
Existing Patient (less than 3 yrs since last visit
Choose a date for the appointment you would like to request
Choose a time you would like to request for your appointment
When is the best time to contact you?
How did you hear about us?
Real Yellow Pages (AT&T)
Word of mouth
Already a patient
Yes, I would like to receive notices and special offers by email.
Once you have completed the form please click Submit. Our appointment team will call you to finalize your appointment.