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Mittleman Eye Center
2000 Palm Beach Lake Blvd.
Suite 400
Phone: 561.273.8000
Fax: 561.478.1300
» Maps & Directions

Telephone Prompts:
Press 2: Fax Number & Address
Press 4: Appointments
Press 5: Prescription Refill
Press 6: Billing Department
Press 7: Optical Shop

Emails


  • General
    Questions
  • Billing
    Department
  • Optical
    Shop
  • Question for
    the Doctor
  • Refill a
    Prescription
  • Request an
    Appointment
  • Reschedule/Cancel
    an Appointment

General Questions

Thanks for taking a few minutes to complete this form. To expedite your request, please provide as much information below as you can. Because we value your privacy, your personal information will not be used by us other than to process your request.

Name
Phone
E-Mail
General Questions

By checking this box, I agree to Mittleman Eye Center Privacy Notice. I further acknowledge that I am transmitting information via email on a non-secure website.

Billing Question

Thanks for taking a few minutes to complete this form. To expedite your request, please provide as much information below as you can. Because we value your privacy, your personal information will not be used by us other than to process your request.

Name
Phone
E-Mail
Billing Questions

By checking this box, I agree to Mittleman Eye Center Privacy Notice. I further acknowledge that I am transmitting information via email on a non-secure website.

Optical Shop

Thanks for taking a few minutes to complete this form. To expedite your request, please provide as much information below as you can. Because we value your privacy, your personal information will not be used by us other than to process your request.

Name
Phone
E-Mail
Optical Shop Questions

By checking this box, I agree to Mittleman Eye Center Privacy Notice. I further acknowledge that I am transmitting information via email on a non-secure website.

Question for the Doctor

Thanks for taking a few minutes to complete this form. To expedite your request, please provide as much information below as you can. Because we value your privacy, your personal information will not be used by us other than to process your request.

This form is not for urgent matters. Please contact the office by phone at (561) 478-2015 for any urgent care, call 911, or proceed to the local emergency room.

All questions will be recieved by the doctor. Requests will be processed by the end of the business day that they were submitted.

Name
Phone
E-Mail
Questions for the Doctor

By checking this box, I agree to Mittleman Eye Center Privacy Notice. I further acknowledge that I am transmitting information via email on a non-secure website.

Refill a Prescription

Thanks for taking a few minutes to complete this form. To expedite your request, please provide as much information below as you can. Because we value your privacy, your personal information will not be used by us other than to process your request.

Name
Phone
E-Mail
Prescription
Pharmacy Name
Pharmacy Phone Number
Special Instructions

By checking this box, I agree to Mittleman Eye Center Privacy Notice. I further acknowledge that I am transmitting information via email on a non-secure website.

Request an Appointment

By taking a few minutes to complete this form, you, or your representative acting on your behalf, can request an appointment with a Mittleman Eye Center specialist. To expedite your request, please provide as much information below as you can. Because we value your privacy, your personal information will not be used by us other than to schedule an appointment.

This form is not for urgent appointments or for appointments that you may need today. If you need emergency help, call 911 or go to your local emergency room.

Patient's Full Name
Sex:
Male Female
Patient's Date of Birth
Phone
Alternate Phone
E-Mail
Address
City
State
Zip
Please list your insurance plans
Is your health insurance HMO?
Yes No
Did a physician refer you to us?
Yes No
What is your diagnosis or complaint?
My symptoms began about
Any other helpful information
Location
West Palm Beach Juno Beach

By checking this box, I agree to Mittleman Eye Center Privacy Notice. I further acknowledge that I am transmitting information via email on a non-secure website.

Reschedule / Cancel an Appointment

By taking a few minutes to complete this form, you, or your representative acting on your behalf, can reschedule or cancel an appointment with a Mittleman Eye Center specialist. To expedite your request, please provide as much information below as you can. Because we value your privacy, your personal information will not be used by us other than to schedule an appointment.

This form is not for urgent appointments or for appointments that you may need today. If you need emergency help, call 911 or go to your local emergency room.

Name
Phone
E-Mail
You need to
Reschedule Cancel
Appointment Date
Appointment Time
Questions for the Doctor

By checking this box, I agree to Mittleman Eye Center Privacy Notice. I further acknowledge that I am transmitting information via email and a non-secure website.

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