Appointment Request Form

Name: Eye Care Hawaii
Address: 34 W Kawailani St, Hilo, HI, 96720, US
Telephone: 808-935-8887
Price range: $000 - $300

Online patient scheduling is only for non-emergency eye visits. Please fill out the form below to make an appointment. If you are having an eye emergency, please call our office at 935-8887.
Full Name*
Phone*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Date of Birth*
Month
Day
Year
Email

Medical Insurance
Medical Insurance Name
Member ID Number
Employer Name
Family Eye Exam Details
Please list any other family members who will be requiring an appointment as well.
Family Member Name #1
DOB #1
MM slash DD slash YYYY
Family Member Name #2
DOB #2
MM slash DD slash YYYY
Family Member Name #3
DOB #3
MM slash DD slash YYYY
Family Member Name #4
DOB #4
MM slash DD slash YYYY

Appointment Details
Preferred Date*
Preferred Date
Preferred Date
Preferred Time
- Morning
- Afternoon
- Evening
I'm making an appointment for:
Other reason for appointment:
Comments and Questions
Please note that the date and time you requested may not be available. We will contact you to confirm your actual appointment details.
Privacy Policy
Health Information Protection*
- I have read and agree to the Privacy Policy
Email Consent*
- I agree to receive email communication from your practice
Comments
This field is for validation purposes and should be left unchanged.

Medical Insurance