Appointment Request Form Appointment Request Form Basic form for clients to request an appointment with the practice. Please fill in the form below to setup an appointment.This appointment is for:* A Child An Adult Reason(s) for Appointment* Eye Exam Myopia Management (For Kids/Teens) Orthokeratology for Kids & Adults Dry Eye Assessment Vision Therapy Evaluation Post Concussion / Head Trauma Eval Sports Vision Training Other Reason 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 patient Returning patient Please let us know if you are a new or existing patient.Name* First Last Phone*Email* Best Time to be Reached for Confirmation* : Hours Minutes AM PM AM/PM CommentsCAPTCHACommentsThis field is for validation purposes and should be left unchanged.
*Open Saturday by appointment only.