Request Appointment

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Do not use this form for any emergency or urgent eye care request. If you are in an emergency, please call our practice.

Emergency eye care may constitute any of the following: 1. vision loss; 2. different size pupils; 3. double vision; 4. bleeding from the eye; 5. Swelling; 6. eye pain that doesn't lessen on its own; and/ or 7. eye pain accompanied by a headache. If you experience any of the following issues above, we recommend that you seek immediate medical attention.

For after-hour eye emergencies, please visit your local ER or Urgent Care Center, or dial 911.

Are you a new or returning patient?*

Name*

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Mobile Phone*

Email*

Date of Birth*

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Date of Birth

Please let us know when you would prefer to have your appointment. Our hours are listed on our location page.

Appointment Type*

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Reason for Appointment

Please provide a reason for your appointment. Details are stored securely and not sent by email.

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Patient Type

New patient

Returning patient

Please let us know if you are a new or existing patient.

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Best Time to be Reached for Confirmation

Notes

Phone

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