Schedule Appointment

To schedule an in-office examination, please complete the form below or call one of our offices. After submitting the form, a member of our scheduling team will contact you within one business day to schedule your appointment.

Please note: Submitting this form does not confirm or reserve an appointment time.

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)

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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Serving the State of Michigan