Barnes Vision Clinic
Barnes Vision Clinic

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

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

  • How did you find us?
  • Whom may we thank for referring us?
  • Appointment Information

  • Doctor:
  • Select a preferred appointment date and time
  • Date:
  • Time:
  • Reason for Visit:
  • Specify "Other":
  • Insurance Information

  • Vision Benefits:
  • Specify "Other":
  • Name of Primary Insured:
  • Comments/Questions: