Premier Glaucoma & Eye Care Appointment Request 1160 S. Linden Road, Flint, MI 48532 Phone: 810-820-8230 Fax: 810-820-8937 Name* Patient’s first name Patient’s last name Responsible party name (if different) First Last Patient’s date of birth* MM slash DD slash YYYY Patient Type*New PatientEstablished PatientPreferred appointment time*First Available / Any timeMorningsAfternoonsPreferred appointment day*AnyMondayTuesdayWednesdayThursdayFriday Phone*Email* Preferred Contact Method* By Phone By Email By Text Purpose for visit or other information Δ