For a medical emergency, call 911 or for immediate eye care, call Amerine Eye Care in West Little Rock or North Little Rock @ 501.223.2020

Walk-ins are always welcome!

You may request an appointment by completing the information below:

*Office Location:	West Little RockNorth Little Rock
*Optometric Physician Preference:	No PreferenceDr. Perry AmerineDr. Michelle DurhamDr. Doug Barton
*Name	Mr.Ms.Mrs.Dr.
*Date of Birth:	--
*Address
*Phone:	--
Email:

---

Medical Insurance

Please select one from the approved provider list. Insurances not listed are considered out of network and are not accepted for assignment.

*Primary Insurance	Blue Cross Blue Shield Humana Gold Choice Qual-Choice Medicaid Medicare Municipal Health None
*Subscriber / Member ID
*Provider Customer Service Telephone#
*Secondary Insurance	Blue Cross Blue Shield Humana Gold Choice Qual-Choice Medicaid Medicare Municipal Health None
*Subscriber / Member ID
*Provider Customer Service Telephone#

---

Vision Insurance

Please select one from the approved provider list. Insurances not listed are considered out of network and are not accepted for assignment.

*Vision Insurance	Avesis Superior Vision Spectera- Glasses Exam Only United Health Vision- Glasses Exam Only Optum Health-Glasses Exam Only None
*Subscriber / Member ID
*Provider Customer Service Telephone#

---

*Appointment Request Date:
*Request time range:	Between 9am 10am 11am 12pm 1pm 2pm 3pm 4pm 5pm and 9am 10am 11am 12pm 1pm 2pm 3pm 4pm 5pm
*Reason for visit:
Notes/Comments/Specifications

*Fields with an asterisk are required.

You will receive a phone call or email confirmation no later than the next business day.