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Request an Appointment

Online Appointment Request

To request an appointment with North Carolina Retina Associates, please complete the form below. Our staff will contact you to confirm your appointment as soon as possible.

Patient Information
Name:
Home Phone:
Cell Phone:
Email Address:
Contact Method: Home Phone
Cell Phone
Email Address
Name of your Primary Eye Doctor:
Appointment Information
Preferred Office Location:
Preferred Day: Monday
Tuesday
Wednesday
Thursday
Friday
Preferred Time: Morning (AM)
Afternoon (PM)
Secondary Preferred Day: Monday
Tuesday
Wednesday
Thursday
Friday
Secondary Preferred Time: Morning (AM)
Afternoon (PM)
Question/Comment:

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