Appointment Form

Appointment Request Form

Please fill out the form below and submit for an appointment request. Please make sure the form is submitted by looking for verification.

Please Note: Form has been tested with Internet Explorer, Chrome, Firefox & Safari.

What do you need to be seen for? Check all that apply.

If you are needing a contact lens fitting and evaluation, have you worn contacts before?

DAY(S) PREFERRED (Required) - Please pick more than one.


*We are closed Sundays and Mondays

Doctor Preferred (Required)
" "Dr. Van Do (F) [Thursdays, Fridays & Saturdays]

Time(s) Preferred (Required)

Please Fill Out The Fields Below If You Are Using Medical AND/OR Vision Insurance

Medical Insurance





Vision Insurance


OUT OF NETWORK WITH: Spectera and Davis Vision. (PATIENTS CAN FILE OUT OF NETWORK CLAIM)





Additional Notes For Wink Eye Care Staff

Please look for verification after submitting



Once you have the appointment form completed, feel free to proceed with our Secure Online Patient Form.

 

Current Social Distancing Safety Requirements for all Patients and Patrons (updated: 01/01/2022)

Please keep in mind that we have everyone’s health and safety on the top of our mind when we do plan to re-open. As a patient and or customer, we do ask that you follow these recommended guidelines before coming in.

As a patient and or customer, we do ask that you follow these recommended guidelines before coming in

  1. Face masks are encouraged but not required for all patients and patrons.
  2. We will be screening all patients and customers with non-contact forehead thermometers. Any temperature at 100 or higher will be rescheduled.
  3. We are requesting that patients with symptoms of illness, and those at a higher likelihood of exposure to ANY health related viruses, postpone their visit.
  4. Only the patient is allowed in the exam room with the Doctor. Only one parent or guardian is allowed in the exam room if the patient is a minor (17 years of age or younger)
  5. Online patient intake forms should be completed at home to eliminate sharing computers, tablets, and keyboards. These can be done on your phone as well, they just take longer.

Take care, stay safe and we will see you soon.

© 2022 Wink Eye Care