Thank you for your interest in the Yale Eye Center. We would be happy to assist you in scheduling an appointment with one of our physicians. You can simply complete this form and submit it through this web site. Or if you would prefer, you can call our office at 203-785-2020. When using this form, you can expect to hear from us within 72 hours during the work week. Once you have filled out the form, we will be better able to service you and ensure that you are scheduled with the Yale physician specializing in the area most appropriate for your specific needs. (Please note that fields marked with an asterisk are required, and must be completed before the form can be submitted.)
1. Your first and last name
*First Name:.**Last Name:
2. Your email address:
3. Your daytime phone number and best time to call
*Phone:.*Best times:
4. Your mailing address
*Street:
*City:
*State or Province:.*Zip/postal code:
* 5. Name of health insurance plan:
6. Is there a specific Yale Eye Center physician you would like to see? If yes, click on the name from this menu:
* 9. Is this appointment for a child or adult?
Select one: Child....Adult
10. If you do not know the name of a specific physician, we can match you with a Yale Eye Center physician who specializes in the treatment of specific problems listed in this menu. You may click on all that apply to your visit request:
11. Please describe any symptoms you are having and any recent injury or medical condition for which you are seeking care. This will help us match you with the most appropriate eye specialist.
