Eye Clinic

You may schedule an appointment by calling our office
or
REQUEST an appointment date & 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 by phone or by email to confirm your appointment.

(Items with * are required in order to submit your request.)
*Name:
*Address:
*City:
*State/Province:
*Zip/Postal Code:
*Country:
*Phone:	(Example: 555-555-1212)
*Email:
*Requested Date:	/ /
*Requested Time/Range:	Between and
*Reason for visit:

Other comments, questions or special instructions: