Appointment Request Form To schedule an appointment with Dr. Benjamin Azman today, please fill out the request form below. We will reach out to you to confirm the appointment via email or phone. 1 Request Type2 Information Please fill in the form below to setup an appointment.Reason for Appointment* Eye Exam Contact Lenses Specialty Contact Lenses Keratoconus Ortho-k Dry Eyes Medical Other Location*TimoniumMt. WashingtonPatient Type*New patientReturning patientPlease let us know if you are a new or existing patient. Name* First Last Phone*Email* Insurance Provider*AetnaBlue Cross/Blue ShieldCignaDavis VisionMedicareVSPCommentsEmailThis field is for validation purposes and should be left unchanged. This iframe contains the logic required to handle Ajax powered Gravity Forms.