Appointment Request Form

Name: Mallard Eye Care
Address: 1224 Huntsville Highway, Fayetteville, TN, 37334, US
Telephone: 931-438-1771
Price range: $000 - $300

Please fill in the form below to setup an appointment.
Location
- Columbia
- Spring Hill
- Fayetteville
Reason for Appointment
Please provide a reason for your appointment. Details are stored securely and not sent by email.
Preferred Dates and Times*
Please let us know when you would prefer to have your appointment. Our hours are listed on our location page.
Patient Type*
- New patient
- Returning patient
Please let us know if you are a new or existing patient.
Name*
First Last
Phone*
Email*
Best way to reach you for confirmation:*
Date of Birth
Date Format: MM slash DD slash YYYY
Exam Type
A written updated glasses Rx is included when we do a contact lens exam.
Do You Wear Contacts?
- Yes
- No
Vision Insurance Company
Vision Insurance ID #
Primary Member
DOB of the Primary Insurer
Comments
Name
This field is for validation purposes and should be left unchanged.

Follow Us