First Name: (Required)

Last Name: (Required)

Name of Insurance Plan: (Required)

If interested in comprehensive examination, does your vision insurance cover routine exams? (Required)

• Yes
• No
• Not Sure

Please tell us the type of appointment you are requesting, the doctor you would like to see and what location, day and time is best for you.

Type of Appointment: (Required) Select Type of Appointment Comprehensive Vision Exam Evaluation for Medical Condition Referred by Primary Care Physician Referred by Optometrist LASIK Evaluation Cataract Evaluation Cosmetic Evaluation

Doctor: No Preference Dr. Gary Baziz Dr. Donna G. Booth Dr. C. Ross Bregel Dr. Francisco Burgos Dr. Richard C. Edlow Dr. Diane M. Golub Dr. Lauren Gormley Dr. Anjana P. Jindal Dr. Brett W. Katzen Dr. Leeds E. Katzen Dr. Peter T. Lapinsky Dr. Emily P. MacQuaid Dr. Tania S. Marcic Dr. Martin S. Novey Dr. Lori Sportelli Dr. Eric Q. Williams Dr. Amy A. Zimmerman

Preferred Location (Required)

• Bel Air
• Lutherville/ Towson Office
• Mercy Medical Center
• Rosedale Office

Day: (Required) Select A Day Monday Tuesday Wednesday Thursday Friday Saturday (Lutherville Only)

Time: (Required) Select a Time Morning Midday Afternoon Evening (Lutherville Only)

How should we respond to your request for an appointment, by email or telephone?

Email Address:

Phone Number: (Required)

Best time to reach you? Morning Midday Afternoon Evening