Canton Eye Center

Schedule an Appointment

A comprehensive exam may take up to two hours. Please allow adequate time in your schedule. Dilating drops are used and may temporarily blur your vision, and may cause sensitivity to sunlight. We strongly recommend you do not drive immediately after your pupils have been dilated. We suggest you bring a driver if at all possible.
 
Please bring your glasses and a complete list of the medications you take regularly. This is important for a complete medical history.
 
The Eye Clinic is offering this "Schedule an Appointment" form for people who don't have time during our regular business hours to call in and schedule an appointment. Please fill out all the information below and press the submit button once.
 
Your appointment won't be officially scheduled until a representative from our office either emails or calls you to confirm your appointment.

Patient Information
First Name
Last Name
Day-Time Phone
Email Address
Address
Apt #
City
State & ZIP
Date of Birth
month
day
year
   
Have you been to the Eye Clinic Before
yes
no
If this is your first visit, how did you hear about us?
If you have, how long has it been since your last visit?

Reason for Appointment
Is this a routine eye exam?
yes
no
What (if any) specific problems are you experiencing?
Do you wear contact lenses?
yes
no

Scheduling Information
What days are convenient for you?
What Times are convenient for you?
Which Doctor would you like to schedule with?
Which Office do you prefer ?
How would you like us to confirm your appointment ?
Day time phone

Insurance
Please list your medical insurance providers:
Primary Medical:
Secondary Medical:
Please list your vision insurance providers:
Primary Vision:
Secondary Vision:
I have read and accept the privacy policy
I DO NOT accept the privacy policy and would rather call