First name
Last name
Email
Phone Number
This is the number we will call you from 602-955-1000 which will show up on your caller id
Are you an existing patient?
Yes
No
Date of Birth
Month
Day
Year
Date of Birth
To select your birth year
- click the calendar icon then click/tap "January 1970" between the arrows
MM
/
DD
/
YYYY
What service are you interested in?
Please select
Diabetic Macular Edema
Diabetic Retinopathy
Flashes
Floaters
Low Vision (Referral Only)
Macular Degeneration
Macular Hole
Macular Pucker (Epiretinal Membrane)
Posterior Vitreous Separation
Retinal Artery Occlusions
Retinal Detachment
Retinal Tear
Retinal Vein Occlusions
Uveitis
Please select
How can we help you?
Please select
Billing
Contacts/Glasses Prescription
Medical Prescription
My Upcoming Appointment (confirm, cancel, question)
Scheduling an Appointment
Patient Portal
Other
Please select
Please choose one of the following:
Please select
Business Inquiry
Media Inquiry
Other
Please select
Clinic Location
This is very important, please choose carefully to have you submission properly routed. If you are existing patient, please choose the location you regularly visit
Please select
Phoenix North, AZ
Phoenix Biltmore, AZ
Gilbert, AZ
Mesa, AZ
Peoria, AZ
Bullhead City, AZ
Flagstaff, AZ
Cottonwood, AZ
Kingman, AZ
Goodyear Litchfield Rd, AZ
Goodyear, AZ
Prescott Whipple St, AZ
Payson, AZ
Lake Havasu City, AZ
Scottsdale Hayden and Shea, AZ
Sacaton, AZ
Prescott Valley Glassford Hill Rd, AZ
Sedona, AZ
North Scottsdale, AZ
Scottsdale McCormick, AZ
Tuba City, AZ
Sun Lakes, AZ
Sun City West, AZ
Yuma Foothills, AZ
Yuma 28th St, AZ
Please select
Include any additional information so our clinic staff can best help you:
Include any details about the best time of day to reach you
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