Request an Appointment

Request an appointment date and time
by filling out the following information.
Appointment times are subject to availability.
We will do our best to accommodate your request.
Our office will contact you to confirm your appointment.
If this is a medical emergency, please call 911.

*First Name:	:
*Last Name:	:
Address:	:
*City:	:
Zip:	:
* Age	:
*Phone	:		Cell Phone
*E-Mail	:
Plan Sponsor	:	Health Benefits Plan, Farm Bureau, Labor Union, Employer, Etc.
Contact Lens Wearer?	:	Yes No
Appointment Information
State	:
Office Location	:
Requested Date	:
Appointment Date must be at least 1 week from today*. We will be contacting you shortly to confirm your requested appointment date and to collect your $50 refundable deposit. If you would prefer an earlier appointment date please call us to schedule.
Requested Time of Day	:

Other Comments, Questions, or Special Instructions

To Find A Location

1-877-306-2010

Request an Appointment

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