Make an Appointment
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To request an appointment, please complete the form below. Be sure to complete all *required information before you submit.
Or call the Charles Retina Institute at (901) 767-4499 or (800) 423-0404 Monday through Friday, 8 a.m. to 5:00 p.m. EST.

Name :
Email :
Phone :
Alternate Phone :
Current Patient : Yes / No
Appointment Reason :
Insurance :
(Important : If your visit requires an insurance referral, please contact your insurance or primary care provider for authorization prior to your visit.)
Referring Doctor :
Preferred Day or Week :
Preferred Time of Day : Morning / Afternoon
Physician Preference (if any) :
 

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