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Located at 5 Bellport Lane in Bellport, NY. We are open on Saturdays!

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Our Eye Doctor
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Home » Contact Us » Appointment Request Form

Appointment Request Form

Please fill in the form below to setup an appointment.
Patient Type*
- New patient
- Returning patient
Please let us know if you are a new or existing patient.
This exam is for:*
- A Child
- An Adult
Our practice specializes in Myopia Management for children. Nearsightedness / myopia is one of the leading causes of eye disease in adults, but myopia management can slow down myopic progression in your child and help prevent glaucoma, macular degeneration, etc. If you haven't heard about myopia management, please click here here to learn more about it. If it is relevant for your child, our eye doctor will introduce you to myopia management at the eye exam. Feel free to contact us at 631-286-4014 before your child's eye exam to learn more about this service or browse our website for further information.
During your exam, would you be interested in hearing about controlling nearsightedness progression?*
- Yes
- Not at this time
Reason for Appointment*
- Child is getting more nearsighted each year. Learn More Here
- Myopia Management or Control
- Ortho-K or CRT or GVSS (Vision Correction)
- Vision Therapy (Eye Therapy)
- Reading & Learning Problems in Children
- Lazy Eye (Amblyopia) or an Eye Turn (Strabismus)
- Child with Special Needs
- Attention or Concentration Problems
- Regular Eye Exam
- Contact Lens Exam
- Other
Choose from any of the following options.
Reason for Appointment*
- Tearing or watery eyes
- Sensitive or rubbing eyes
- High Astigmatism or High Prescription
- Keratoconus or Irregular Cornea
- Poor vision wearing contacts or glasses.
- Safe alternative to LASIK w/o surgery
- Ortho-K (Vision Correction)
- Eye Conditions and Diseases
- Headaches & Migraines
- Dizziness, Vertigo, Poor Balance
- Attention or Concentration Problems
- Post concussion, head trauma, stroke or brain injury
- Improve Visual Abilities for Athletes
- Vision Therapy for Adults
- Regular Eye Exam
- Contact Lens Exam
- Other
Please Specify*
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Reason for Appointment
Please provide a reason for your appointment. Details are stored securely and not sent by email.
Preferred Date & Times
Please let us know when you would prefer to have your appointment. Our hours are listed on our location page.
Name*
First Last
Phone*
Email*
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Best Time to be Reached for Confirmation*

: Hours

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Vision Coverage*
Please note: Vision Coverage is usually not the same as your Health Insurance (some exceptions include Fidelis and Health First). If you are not sure what Vision Coverage you have, we recommend you contact your Human Resources Department or call your Health Insurance Company to find out what the vision rider is.
Health Insurance*
How did you find us?*
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Patient History Form

Bellport Perspective Eye Care

5 Bellport Ln
Bellport, NY 11713

Phone: 631-286-4014
Email: bpeyecare0418@gmail.com
(Do not send personal health information by email.)

Monday: 10:00 AM - 6:00 PM
Tuesday: 10:00 AM - 7:00 PM
Wednesday: 10:00 AM - 6:00 PM
Thursday: 10:00 AM - 7:00 PM
Friday: 10:00 AM - 6:00 PM
Saturday: 8:30 AM - 2:30 PM
Sunday: Closed

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Bellport Perspective Eye Care
5 Bellport Ln
Bellport, NY 11713
Phone: 631-286-4014
https://www.bellporteyecenter.com

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