If you would like to schedule an appointment, simply complete the form below to let us know a little bit about you. Items outlined in red are required fields.

Once you submit the form, a staff member will give you a call to set up an appropriate time. This form helps us provide you with more efficient service — and will save you time when you arrive for your first appointment.

If you prefer not to use this form for any reason, then give us a call at 970.568.7161. We look forward to seeing you!

Patient Information
Mr. Miss Mrs. Ms. Dr.
Name:
Address:	Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Date of Birth:
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Spouse or Parent(s) Name:
Person Responsible for Account:
Emergency Contact:
Preferred Day and Time:	Select a Day Monday Tuesday Wednesday Thursday    Select a Time Early Morning Late Morning Early Afternoon Late Afternoon
Medical Insurance Information
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Address:	Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Male Female
Insured's Name:
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Insurance Information:
Patient Relationship to Insured:	Self Spouse Child Other
Patient Status:	Single Married Full Time Student Part Time Student Employed
Vision Insurance Information
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Address:	Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Male Female
Insured's Name:
Insured's Date of Birth:
Insurance Information:
Patient Relationship to Insured:	Self Spouse Child Other

Equipped to improve your vision

Larry Eklund, O.D. | 8251 Wellington Boulevard | Wellington, CO 80549 | P: 970.568.7161