Name* Phone Email* Preferred Date MM slash DD slash YYYY Preferred TimeMorningAfternoonEveningMessage*Insurance We are an out-of-network provider for all insurance providers. We do not submit claims for any Vision Therapy Services. If you would like to submit to your insurance for reimbursement, we will provide invoices with the necessary codes. Privacy and Consent I consent to receive messages from Cary Vision Therapy and understand that I can opt out at any time by contacting the clinic. Please use this form for general information purposes only. DO NOT send personal health information through this form. Specific patient care must be addressed during your appointment.Please complete the following form to request an appointment. Please also note that availability will vary depending on your request. Your appointment will be confirmed by phone by a member of our staff. Thank you!PhoneThis field is for validation purposes and should be left unchanged.
