Appointment Request Form

First Name: (Required)

Last Name: (Required)

Name of Insurance Plan: (Required)

If interested in comprehensive examination, does your vision insurance cover routine exams? (Required)

Yes

No

Not Sure

Please tell us the type of appointment you are requesting, the doctor you would like to see and what location, day and time is best for you.

Type of Appointment: (Required) Comprehensive Vision Exam Evaluation for Medical Condition Referred by Primary Care Physician Referred by Optometrist LASIK Evaluation Cataract Evaluation Cosmetic Evaluation

Doctor: No Preference Dr. Richard A. Adler Dr. Gary Baziz Dr. Donna G. Booth Dr. C. Ross Bregel Dr. Francisco Burgos Dr. Richard C. Edlow Dr. Diane M. Golub Dr. Lauren Gormley Dr. Brett W. Katzen Dr. Leeds E. Katzen Dr. Peter T. Lapinsky Dr. Emily P. MacQuaid-McCartney Dr. Tania S. Marcic Dr. Martin S. Novey Dr. Eric Q. Williams

Preferred Location (Required)

Lutherville/ Towson Office

Mercy Medical Center

Day: (Required) Monday Tuesday Wednesday Thursday Friday Saturday (Lutherville Only)

Time: (Required) Morning Midday Afternoon Evening (Lutherville Only)

How should we respond to your request for an appointment, by email or telephone?

Email Address:

Phone Number: (Required)

Best time to reach you? Morning Midday Afternoon Evening