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Reason for Appointment

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Preferred Date & Times

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Patient Type*

New patient
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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 631-284-4502 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

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Best Time to be Reached for Confirmation*

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Vision Coverage*

Health Insurance*

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.

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Appointment Request Form

Bellport Perspective Eye Care