Please use this form for general information purposes only. DO NOT send personal health information through this form. Specific patient care must be addressed during your appointment.Please complete the following form to request an appointment. Please also note that availability will vary depending on your request. Your appointment will be confirmed by phone by a member of our staff. Thank you!Doctor*No PreferenceDr. Thoai Peter BuiDr. Minh NguyenReason for AppointmentGlasses and eye health checkupGlasses, contact lenses, and eye health checkupDiabetic eye exam (recommended for all patients with diabetes)Red eyeEye painFlashes and or floatersLoss of vision or sudden blurry visionOther reasonIf Other:Preferred Date & Times*Patient Full Name* First Last Phone*Email* Best Time to be Reached for Confirmation* : HH MM AM PM CAPTCHAPatient Type*New patientReturning patientPlease let us know if you are a new or existing patient.If you are a returning patient, has your insurance changed since your last visit?NoYesMedical Insurance CarrierID#Vision Insurance CarrierID#Patient Date of BirthPatient AddressAre you the primary insured?YesNoPrimary Insured Full NamePrimary Insured Date of BirthPrimary Insured AddressCommentsPhoneThis field is for validation purposes and should be left unchanged.
