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Mid South Retina Associates - Appointment Request

Please contact our office by phone or complete the appointment request form below. Our scheduling coordinator will contact you to confirm your appointment. It is also advised that you check with your insurance provider prior to making an appointment request to determine if a referral is needed prior to appointments being made. Please do not use this form to cancel or change an existing appointment.

ATTENTION: For urgent eye problems, please call to the office immediately. After hours calls will be connected with our answering service.


Items in bold are required.
Are you a current patient?
Best time(s) to call?

Which office location(s) would you prefer for your appointment?

Preferred day(s) of the week for an appointment?
Preferred time(s) for an appointment?
Please describe the nature of your appointment (e.g., consultation, check-up, etc.):

Note: Messages sent using this form are not considered private. Please contact our office by telephone if sending highly confidential or private information.