Consultation Connection Form

The contact form below is for new consultation patients.

First name

Please enter the patient's first name.

Last name

Please enter the patient's last name.

Please enter the patient's email.

Phone

Please enter the patient's phone number.

Birthday

Month

Day

Year

Patient's date of birth.

Note: Patient records must be encrypted if uploaded here. Please do not send HIPPA information unencrypted. You may send a passcode to info@atlantacorneacare.com

I would like a consultation for

Poor vision after refractive surgery.

A cornea condition or disease.

Poor comfort in current corrective lenses.

Poor vision in current corrective lenses.

Cornea Shaping/myopia control

Other

I understand this form isn't for emergency communications. I understand that the consultation fee is $210 and will be due at appointment scheduling. I am authorizing The Atlanta Cornea Care Center - Dr. Kenyatta Brantley, Optometrist (P.C.) to receive and review my vision records in preparation for my consultation appointment.

Signature

Signature field is empty.

You may sign this to begin the records release process.

Address

37 Calumet Pkwy, Bldg. G.,

Ste. 101

Newnan, GA 30263

Phone

(229) 800- 4712

info@atlantacorneacare.com

A picture of the front of the Atlanta Cornea Care Center building G.

Consultation Connection Form

Atlanta Cornea Care Center Dr. Kenyatta Brantley, Optometrist (P.C.)

Atlanta Cornea Care Center
Dr. Kenyatta Brantley,
Optometrist (P.C.)