Schedule Appointment

To save time before your appointment, fill out this form and submit to our office.

Select a Choice
First Name
Middle Name
Last Name
Sex (as shown on insurance)
Date of Birth (enter month-day-year)
Address
- Street Address
- Address Line 2
- City
- State / Province / Region
- Postal / Zip Code
- Country
Mobile Phone
Work Phone
Home Phone
Email Address
Employer
Occupation
Social Security Number
Vision Insurance

None
VSP (Vision Service Plan)
Davis
EyeMed
Spectera
SVS (Superior Vision Service)
Primary Member
Relation
Primary Member Date of Birth (enter month-day-year)
Primary Member ID / SS #
I authorize Drs. Babington and Babington to release my personal health information (example: Glasses or Contact Lens Rx, billing information, dispensing of physical glasses or contacts) to the following individuals.

Acknowledgment and Consent: by submitting this form electronically you agree to and understand authorization by “Electronic Signature”.