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Telemedicine – Zion Eye Institute

    Telemedicine Form

    *All Fields Required*

    First Name:

    Last Name:

    Date of Birth (MM/DD/YYYY):



    Contact Preference:

    Video ConferencePhone Call

    Mailing Address (Street, City, State, Zip):

    Brief Description of Problem:

    Insurance Company:

    Have you been seen at our office in the last 12 months?


    Photocopy of Drivers License

    Photocopy of Insurance Card

    I agree and understand that it is my responsibility to contact my insurance company regarding coverage. I understand that I am responsible for payment of this telemedicine service as well as any deductible, co-pay, or co-insurance amounts that may be billed to me.

    Our Locations

    St. George

    Zion Eye Institute:
    1791 East 280 North
    St. George, UT 84790

    (435) 656-2020
    toll free:
    (877) 841-2020
    Santa Clara

    Zion Eye Institute – Eye Care Santa Clara, Utah
    1100 Canyon View Dr. Unit G
    Santa Clara, UT 84765

    (435) 656-2020
    toll free:
    (877) 841-2020

    Zion Eye Institute – Eye Care Mesquite Nevada
    1301 Bertha Howe Ave. Suite 11
    Mesquite, NV 89027

    (435) 656-2020
    toll free:
    (877) 841-2020

    Contact Us

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