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.This exam is for: A Child An Adult Reason for Appointment* Vision Therapy (Eye Therapy) Reading & Learning Problems in Children Lazy Eye (Amblyopia) or an Eye Turn (Strabismus) Child with Special Needs Attention or Concentration Problems Regular Eye Exam Contact Lens Exam Other Choose from any of the following options. Reason for Appointment* Safe alternative to LASIK w/o surgery Ortho-K (Vision Correction) Headaches & Migraines Dizziness, Vertigo, Poor Balance Attention or Concentration Problems Post concussion, head trauma, stroke or brain injury Vision Therapy for Adults 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*CommentsCAPTCHAEmailThis field is for validation purposes and should be left unchanged. Δ
