Prospective Student Request Form

Thank you for your interest in the Doctor of Optometry Program at the University of Alabama at Birmingham. Please complete and submit the form below to be added to our contact list and/or to ask questions about our program. You will receive a response to your question(s) in 3-5 business days. Your contact information will be added to our database enabling us to send you updates in the future.

First Name:   
Last Name:   
Street Address Line 1:   
Street Address Line 2:
State or Province:   
Postal Code:   
Email Address:     
Preferred Phone:   
Alternate Phone:
School Attending or Attended:   
Year in School:
Date of Expected Graduation or Graduation:  (MM/DD/YYYY) 
Degree Expected or Earned:   
Questions for the UABSO Admissions Office:
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