Schedule an Appointment

To schedule an appointment, either pre-register using our Online Appointment Form below or Call 1-215-276-6111. To pre-register, fill out the form below completely, including all insurance information and preferred appointment time and date, and a representative from The Eye Institute will contact you to confirm within 24 - 48 hours. While we cannot guarantee a specific date or time, we will make all efforts to do so.

• For information on what you need to bring to an appointment.
• For Location and Hours

If you are experiencing problems with your vision or eyes that you consider to be an emergency (such as sudden loss or decrease of vision or severe eye pain), do not use this form to submit an appointment request. Please dial 215-276-6000 and choose option 1 from the telephone menu to receive emergency triage or go to an emergency room.

Patient Information (*required information)
*Patient First Name
*Patient Last Name
Patient Age	0 - 5 6 - 18 19 - 29 30 - 39 40 - 49 50 - 64 65+
*Address
Address2
*City
*State	Zip
*Day Phone Number(numbers only)	Area Code                        Phone Number
Is Patient a TEI Employee or Student?	TEI Employee Student
Contact Name (if different than Patient above)
Contact First Name
Contact Last Name
Contact Email
Insurance Information
Insured Name
Medical Insurance Plan
Relationship to Insured	Spouse Child Dependent Self
Employer
Employer Address
Vision Plan
Policy #
Group #
Reason for Visit (Select as many as apply)
Contact Lens Evaluation Eye Pain Discharge From Eye Red Eye or Lid Flashes or Floaters Annual/Biannual Eye Exam Loss of or reduced vision Vision Therapy Continuing/Follow-up Care Perceptual Evaluation Headaches Other Diagnostic Testing/Evaluation (Visual Fields, HRT, OCT)
Comments
Appointment Time Preference	Morning (Monday - Saturday) Afternoon (Monday - Friday) Evening (Tuesday - Wednesday Only)
Appointment Date Range? Please select a date range for the appointment. Click the "select date" to reveal a calendar to select dates
Begin Date            Select Date	End Date             Select Date
Best way to contact you to Confirm the appointment.
*Best Contact Phone(numbers only)	Area Code    Phone Number
*Best time to call	Morning Afternoon Evening
	*Required Fields