Appointment Request Form Please fill in the form below to setup an appointment. You can also submit the Patient History form here (opens in a new tab).Appointment Location*Family EyeCare Clinic - MentorFamily EyeCare Clinic - PainesvilleKane and Figler OptometryTanglewood Family EyeCareInsurance Carrier*AetnaAnthem Blue Cross Blue ShieldBlue ShieldCaresourceCignaCigna SummacareComp BenefitsCoresourceEyeMedHumanaMedicaidMedicareMedical MutualMMOTricareUHCUnited HealthcareVision Benefits of AmericaVSPSelf Pay/NoneInsured Name*Members Insurance ID*Doctor*Brian J. Kane , O.D.Stephen A. Figler, O.D.Todd Dalessandro, O.D.Jocelyn Pettitt, O.D.Lauren Tedesco, O.D.Any DoctorReason for AppointmentPlease provide a reason for your appointment. Details are stored securely and not sent by email.Preferred Date & Times*Please let us know when you would prefer to have your appointment. Our hours are listed on our location page.Patient Type*New patientReturning patientPlease let us know if you are a new or existing patient.Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Name* First Last Phone*Email* Date of Birth* Best Time to be Reached for Confirmation* : HH MM AM PM CommentsSave Time: Submit the Patient History form online! (form will open in a new tab)NameThis field is for validation purposes and should be left unchanged.