Request an Appointment

Please fill out the form below to request an appointment online. A staff member will call you to verify your appointment.

Fields marked with a (*) are required.

First Name*

Last Name*

Date of Birth* (mm/dd/yyyy)

Daytime phone number* (where we can call you to verify your appointment)

Have you been to our office before?*
Yes No

Which doctor are you requesting?

Is there a date and/or time that works best? (morning/afternoon, etc.)

Do you have any vision insurance?*
   VSP
   Medicare
   Medicaid
   Other/unsure
   None

Download new patient forms:
Medical History Questionnaire