Appointment Request Form Please fill in the form below to setup an appointment.Patient Type* New patient Returning patient Please let us know if you are a new or existing patient.Name* First Last Date of Birth* MM slash DD slash YYYY Email* Phone*Preferred Date & Times*Please let us know when you would prefer to have your appointment. Our hours are listed on our location page.Reason For Appointment* Vision and Health Assessment Dry Eye Test LASIK/Smile Consult OrthoK Lens Consult Contact Lens Fitting Vision Therapy Exam (Vision Development/Concussion) 90 min Comments (Language Preferred)Opt-in to receive important communications from us. You can change you preferences at any time. Yes, I want to receive communications . CAPTCHAEmailThis field is for validation purposes and should be left unchanged.