Dr. Trevor J. Cleveland - Optometric Physician 1717 Centennial Blvd., Suite 2 
	Springfield, Oregon 97477 
	541.747.0616
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Schedule an Appointment

Please fill out the form below and we will contact you with an appointment time. Required fields are marked with asterisks (*).

New Patients
Joining our patient community? Please complete the patient history form before your first office visit. After you fill out the form online you may submit it and you will receive a confirmation e-mail. There is no need to print it out, we will save your information for the time of your appointment.

This will save you time and make the office administration process easier.

Existing Patients
If you have moved or any of your patient information has changed please contact our office at (541)747-0616.

 

The security of your information is very important to us. This form is fully secure and your information will be protected. To learn more about the security measures used on this form, click the security logo to the right.

 

Patient Information

Patient Name: *

Contact Name:

Relation to Patient:

Home Phone: *

Work Phone:

Email Address: *

 

Are you currently a patient of Dr. Cleveland's? *

Yes  No  

What is the reason for the appointment? *

Vision and eye health exam
Medical concern
Other concern

What concerns, if any, would you like to speak to the doctor about:

 

Office Hours

Monday-Thursday: 9:00 am to 5:00 pm

Friday: 10:00 am to 3:00 pm

    * No lunch closure.

 

Scheduling Information

Please enter up to three times that would work well for you (i.e. Thursday mornings" or "Wednesdays around 3pm").

 

First Choice:

Second Choice:

Third Choice:

 

Confirmation

How do you prefer to be contacted? *

Email  Phone  

 
 

It may take a moment to submit your information. Please wait for a confirmation message.