Skip to main content
FAX 770-489-8318

We’re inside the Douglasville Sam’s Club Optical at 6995 Concourse Pkwy, Georgia.

Map
Menu

Vision gives us the
power to dream big!

Vision gives us the
power to dream big!

Home » Contact Us » Appointment Request Form

Appointment Request Form

This appointment request form is for NON-URGENT care. Please call or text our office directly at 770-917-2221 if need faster assistance. For emergencies, please call 911 or find the nearest urgent care center.

  • Please fill in the form below to setup an appointment.
    Please check all that apply. **PLEASE NOTE: If this is an urgent visit, we recommend contacting our office by calling or texting 770-917-2221. Response to requests may take 48-72 hours.
    Please let us know what day(s) and time(s) you would prefer to have your appointment. THIS IS NOT A GUARANTEE OF YOUR APPOINTMENT UNTIL OUR STAFF CONTACTS YOU AND CONFIRMS IT BY PHONE, TEXT OR EMAIL. Please be aware that our reminders are just a courtesy, and it is ultimately the responsibility of the patient/guardian to note the appointment date and time. Please read our APPOINTMENT POLICY on cancellation, rescheduling, and no shows.
  • Hidden
    Please let us know what day(s) and time(s) you would prefer to have your appointment. THIS IS NOT A GUARANTEE OF YOUR APPOINTMENT UNTIL OUR STAFF CONTACTS YOU AND CONFIRMS IT BY PHONE, TEXT OR EMAIL. Please be aware that our reminders are just a courtesy and it is ultimately the responsibility of the patient/guardian to note the appointment date and time. Please read our APPOINTMENT POLICY on cancellation, rescheduling, and no shows.
    Please let us know if you are a new or existing patient. For FOR NEW PATIENTS, in order to be seen at our clinic and prevent appointment cancellation, you must complete the online form BEFORE the appointment.
    Insurance appointments may take up to 3-5 business days for verification. We will contact you by phone, text or e-mail if we cannot confirm your insurance. Please click on the following link to confirm the insurances that we accept. Insurance must be verified and eligible before the appointment is made.
    If you are not the primary on the insurance, please put the name and DOB of the primary in the next box.
  • Hidden
    You must bring a valid ID and insurance card to your appointment in order to use your insurance. Please call or text our office at 770-917-2221 if you have any questions.
    You must bring a valid ID and insurance card to your appointment in order to use your insurance. Please call or text our office at 770-917-2221 if you have any questions.
  • If you do not have the ID, we will not be able to verify, and it will delay the appointment request.
    PLEASE NOTE: If you prefer a faster response, please allow our office to communicate by text. Texts are are unencrypted and subject to charges/fees by your carrier that are paid by subscriber. PLEASE REMOVE ANY TEXT BLOCKING OR YOU WILL NOT RECEIVE TEXTS. Email info@miraeye.com if you have not received a text within 3 business days.
  • Hidden
    :
  • PLEASE NOTE! If you do not get a confirmation after pressing submit, please check your email is correct and resend or contact us.
  • Hidden
    Please read our appointment policy and check the box that you have read it. Our reminder system is a courtesy, but you are responsible to notify changes to your schedule.
    You are required to read the Health Policy Protocol. For FOR NEW PATIENTS, in order to be seen at our clinic, you must complete the online paperwork BEFORE the appointment. Please check Yes or No if you agree to the requirements. If you check No, we will not be able to schedule you for the foreseeable future.
  • This field is for validation purposes and should be left unchanged.

NO MEMBERSHIP NEEDED

Our office does not require a Sams Club Membership to be our patient for the eye exam. Please request an appointment online!

x

MASK WEAR WILL BE REQUIRED FOR THE PATIENT REGARDLESS OF VACCINATION PER ADOPTED HEALTH GUIDELINES. We are open by APPOINTMENT ONLY. In order to be seen for the appointment, you must read and stay up to date on our health protocols Read Our Heath/Safety Guidelines Post…