Schedule Appointment



Do not use this form of contact for emergencies. If your question is of an emergent nature, please call Middlesex Eye Physicians at 860-347-7466.

Please select the doctor you wish to see from the list below:

Select Doctor Name:

We are happy to make your appointment via email. To help us identify you properly, please fill out the requested information fully. If you are a new patient to Middlesex Eye Physicians, located under “Patient Forms” is a Welcome Letter and Health Information Sheet for you to print, fill out, and bring to your appointment to reduce wait time.
Also, for your convenience is a downloadable copy of our Patient Privacy Policy.

To schedule an appointment, complete the form below. You will be contacted within two business days with an appointment date and time.

[*] required fields

Please do not use this form for emergencies or questions.

Patient Information

*Patient First Name:

*Patient Last Name:

Street Address:

Street Address2:

City:

State:

Postal Code:

*Date of Birth:

(MM/DD/YYYY)

*Daytime Phone Number:

*Email Address:

*Insurance Carrier:


*Other Carrier:

*Referred by / Source:

Appointment Request

*Doctor:

1^st Choice Time and Location:

*Location:

*Weekday:

*Time of Weekday:

2^nd Choice Time and Location:

*Location:

*Weekday:

*Time of Weekday:

*I am a(n):

*How would you like us to confirm:
your appointment with you?

*Purpose of Appointment:

Comments/Special Requests:

Please confirm all of the information below is correct and press the submit button:

Patient Information

Patient First Name:

Patient Last Name:

Street Address:

Street Address2:

City:

State:

Postal Code:

Date of Birth:

Daytime Phone Number:

Email Address:

Insurance Carrier:

Referred by / Source:

Appointment Request

Doctor:

1^st Choice Time and Location:

Location:

Weekday:

Time of Weekday:

2^nd Choice Time and Location:

Location:

Weekday:

Time of Weekday:

I am a(n):

Confirm Appointment via:

Purpose of Appointment:

Comments/Special Requests:

Locations
MIDDLETOWN OFFICE MAP 400 Saybrook Road Middletown, CT 06457 (860) 347-7466 (860) 347-8300 (Optical Dept)	WESTBROOK OFFICE MAP 4 Grove Beach Road, North Westbrook, CT 06498 (860) 669-5305 (860) 664-8089 (Optical Dept)	EAST HAMPTON OFFICE MAP 240 Middletown Ave, East Hampton, CT 06424 (860) 295-6440	MONTHLY RESOURCE SITE MAP PRIVACY POLICY REFUND POLICY
Copyright © 2010 Middlesex Eye Physicians. All Rights Reserved.

Schedule Appointment

Locations