Appointment Request Form Please note doctor’s schedule: The doctor examines patients on Wednesdays and Fridays. The office is open 6 days a week but Dr. Cross gives patient care on Wednesdays and Fridays only. Ask for an eye exam with Dr. Cross Please fill in the form below to setup an appointment.Reason for AppointmentPlease provide a reason for your appointment. Details are stored securely and not sent by email.Preferred Date & Times (Wednesdays/Fridays only!)*Please let us know when you would prefer to have your appointment. Our hours are listed on our location page. The office is open 6 days a week but Dr. Cross gives patient care on Wednesdays and Fridays only.Patient Type*New patientReturning patientPlease let us know if you are a new or existing patient.Name* First Last Phone*Email* Best Time to be Reached for Confirmation* : HH MM AM PM CommentsEmail If you have TRICARE what plan are you on?TRICARE PRIME EASTPRIME EAST RETIREDSELECT ACTIVE DUTY SPONSORRESERVE ACTIVE DUTY SPONSORDO NOT HAVE (go to next survey)We DO NOT take TRICARE FOR LIFE, TRICARE WEST, TRICARE OVERSEAS, TRICARE families off of ACTIVE DUTY ORDERS, JOHNS HOPKINS USFH, MEDICARE, MEDICAID, or VSP. If we don't take your vision plan we will see you out of pocket.What vision insurance do you have?OTHEREYEMED/ AETNADAVIS VISIONVBAADVANTICANVASPECTERASUPERIOR VISION COMMERCIALSELF PAYN/A I HAVE TRICAREWe take the following INSURANCES however it is your RESPONSIBILITY to find out if Dr. Cross takes YOUR PLAN by contacting your insurance company. We DO NOT TAKE MEDICARE, MEDICAID, or VSP. If we do not take your vision plan we will see you out of pocket.NameThis field is for validation purposes and should be left unchanged.