Eye Specialists of Mid-Florida
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Eye Specialists of Mid-Florida
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First Name
*
Middle Name
Last Name
*
Date of Birth
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Visit Reason / Appointment Type
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Cataract Evaluation
Contact Lens Exam
Diabetic Eye Exam
General Exam Glasses
General Eye Health Exam
Glaucoma Evaluation
Medical Full Exam (If this is an emergency, please call the office immediately)
Other
Email
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Language
English
Spanish
Portuguese
Cell Phone
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Preferred Time
Morning
Midday
Afternoon
Preferred Location
Any Location
Auburndale
Auburndale
Clermont
Clermont Office
Haines City
Haines City Office
Lake Wales
Lake Wales Office
Lakeland Edgewood
Lakeland Harden
Lakeland Harden
Lakeland Highlands
Lakeland Highlands Office
Patient Home Winter Have
Sebring
Sebring Office
Winter Haven
Winter Haven Office
Preferred Provider
Any Provider
Dr. Anisa Patail
Dr. Anisha Patel
Dr. Chelsea Hollier
Dr. Corkins
Dr. Damon Welch
Dr. Daniel Welch
Dr. Daniela Fernandez
Dr. David Loewy
Dr. Edward Attaway
Dr. Hafner
Dr. Hegland
Dr. Loewy
Dr. Nader Moinfar
Dr. Ryan Peardon
Dr. Selina Lin
Dr. William Corkins
Your Care Team
Insurance Provider
Preferred Day of the Week (Check all that apply)
Monday
Tuesday
Wednesday
Thursday
Friday
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