3833 Bedford Cyn Rd.
Suite C101
Corona, CA 92883
Call (951) 898-6979

TELEMED

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Consultation Request
Patient Information
Insurance Information
Dilation Information
Health History

Financial Policy
Consent to Treat Minor
Acknowledgement of Privacy Practice
Authorization to Disclose Health Information
Order Contacts

Order Contacts

Fill out this order form so we can evaluate your request. We will call you to confirm your payment method & order requirements. If you have any questions, please give us a call.

Full Name

Date of Birth (mm/dd/yyyy)

Phone (xxx-xxx-xxxx)

Patient Status

Which eye(s) are you ordering contacts for

Vision Insurance Info (Optional)
Enter plan provider and your ID #
(Note: Medicaid does not cover contact lenses)

Notes

Request Appointment

Office Hours

Mon

9:00 - 6:00

Tue

10:00 - 7:00

Wed

9:00 - 6:00

Thu

9:00 - 5:00

Fri

9:00 - 5:00

Sat

Closed

Sun

Closed

3833 Bedford Cyn Rd.
Suite C101
Corona, CA 92883

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Call (951) 898-6979

Email Us

Eagle Glen Optometry 3833 Bedford Canyon Rd. Suite C101 Corona, CA 92883 Phone: (951) 898-6979 Fax: (888) 818-4787

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