Appointment Request Form

Required Forms
 These online forms can be filled out on screen and printed for you to bring with you to your appointment. Should you have any problems with or questions about these online forms please contact us via E-Mail, using our contact form or call our office at (731) 686-8642.
 Adult Information / history form
Children's Information / history forms must be completed and signed by the person responsible for the child's account (parent or legal guardian) and the child must be accompanied by this responsible party to authorize treatment.
Child Information / history form

To request an appointment, fill out the form below by entering your contact information and preferred date and time. Our staff will do their best to schedule your appointment for the time and date you request and will contact you within one business day to make final confirmation. If you prefer, you can also schedule an appointment calling us at (731) 686-8642.

New patients should arrive 15 minutes early for their appointment. Existing patients should arrive five minutes early.

Fields marked with an " * " below are required.

Name*
 

Phone*
 

E-mail*
 

Street Address*
 

City*                                                                 State*                  Zip*
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Office Hours

Milan:
- Monday thru Friday: 8:30 AM to 5:00 PM
- Friday: 8:30 AM to 3:00 PM
- Closed Saturday & Sunday

Preferred Date*                                                                                          Time*
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Preferred Doctor
 

Insurance Carrier
Carriers listed are some of the organizations that Kizer Family Optometry submits claims to. Select "Other" if your insurance carrier is not in the list. Submitting a claim does not guarantee coverage. Be sure to check with your insurance carrier for specific coverage levels.
 

Additional Notes