Appointment Request Form Basic form for clients to request an appointment with the practice. 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.This exam is for: A Child An Adult Reason for Appointment* Regular Eye Exam Contact Lens Exam Other Choose from any of the following options. Reason for Appointment* Tearing or watery eyes Sensitive or rubbing eyes Eye Conditions and Diseases Regular Eye Exam Contact Lens Exam Other Please Specify* Preferred Date & Times*Please let us know when you would prefer to have your appointment. Our hours are listed on our location page.Name* First Last Phone*Email* How did you find us?*Friend/FamilyGoogle Search/WebsiteSocial MediaDoctor ReferralOtherPlease Specify* CommentsPhoneThis field is for validation purposes and should be left unchanged.