Schedule Appointment

To request an in-office examination, please complete the form below or call one of our offices.

Clinton Township
586.532.3380

Dearborn
313.561.1777

Detroit – Children’s Hospital of Michigan
Department of Ophthalmology
313.745.3937

West Bloomfield
248.538.7400

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Patient Information- Minor Child

Patient Name(Required)

First Middle Initial Last suffix (legal name)

Patient Address(Required)

Street Address Address Line 2 City State ZIP Code

Patient Mobile Phone(Required)

Patient Alternate Phone

Patient Gender(Required)

Female

Male

Other

Patient Birthdate(Required)

Patient Email

Parent / Guardian Information

Please list any person(s) who has legal responsibility to make medical and personal decisions tor the patient/minor child. EXAMPLES: parent(s) listed on the birth certificate, court ordered foster parent, court ordered legal guardian.

Name(Required)

First Middle Initial Last suffix (legal name)

Address Same As Patient(Required)

Yes

Address(Required)

Street Address Address Line 2 City State ZIP Code

Mobile Phone(Required)

Alternate Phone

Email(Required)

Relationaship To Patient(Required)

Mother & Legal Guardian / Parent

Father & Legal Guardian / Parent

Foster Parent & Legal Guardian

Legal Guardian

Other

Specify Relationship If Applicable

Medical Insurance Name(Required)

Subscriber / Policy ID #:(Required)

Schedule Appointment

Patient Information- Minor Child

Parent / Guardian Information

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