Make an Appointment

Please fill out the form below to schedule an appointment. Items in bold are required. We will contact you as soon as possible. Thank you!

• Personal Information

• First Name:
• Last Name:
• Address:
• City:
  State: Zip Code:
• Home Phone:
• Work Phone:
• Mobile Phone:
• Email:
• Date of Birth:
  MM: DD: YYYY:
• Have we seen you before? Yes No
• Refferal Information

• How did you find us? Please Select Refferal from Family or Friend Phone Book Newspaper Web site Dr. Referral
• Whom may we thank for refering us?
• Appointment Information

• Doctor:
  No Preference Dr. Rebecca Barnes Dr. Elizabeth Cole
• Select a preferred appointment date and time
• Date:
  Time: am pm
• Reason for Visit:
  Please Select Comprehensive Eye Exam for Contact Lenses Comprehensive Eye Exam for Glasses Emergency Office Visit Contact Lens Check Dry Eye Treatment/ Follow-up Glaucoma Treatment/ Follow-up Ocular Disease Treatment/Follow-up Laser Vision Correction Evaluation Other
• Specify "Other":
• Insurance Information

• Vision Benefits:
  Chickasaw BlueCross BlueShield City Of Ardmore Medicare Mercy Memorial Health Center Michelin Not Applicable Other
• Specify "Other":
• Name of Primary Insured:
• Comments/Questions: