Appointment Request Form Please fill in the form below to setup an appointment.Requested Date & Times. THIS DOES NOT SET the appointment.*Please let us know when you would like to have your appointment. THIS DOES NOT set the appointment, it is not connected our scheduler. We will reach out to you set up the actual appointment via email or phone and we will do our best to set up your appointment during your preferred times. 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 Date of Birth* Month Day Year Phone*Email* Best Time to be Reached for Confirmation : Hours Minutes AM PM Reason for AppointmentPlease provide a reason for your appointment, such as regular exam or contact exam. Details are stored securely and not sent by email.Vision Insurance*Please provide the vision insurance and member ID number to be used for the exam if any. If the patient will be self pay, please just state "none."CommentsCommentsThis field is for validation purposes and should be left unchanged.