Clinic Appointments

Use this form to request an appointment with one of the doctors in our Vision Clinic or Hearing Clinic.  We will contact you within 1 to 2 business days to schedule a convenient appointment for you.

Clinic Appointment Request

Note: Required fields are marked with (*)
Appointment Type(*)

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Select the type of appointment you want.

First Name(*)
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Last Name(*)
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Date of Birth(*)
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Enter your date of birth as (mm/dd/yyyy) or click the Calendar Popup to pick a date from the calendar. Click on the month and year to quickly change them and then pick the day you were born.

Email Address(*)
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Have you had an exam with us in the past?(*)

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Contact Phone Home
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xxx-xxx-xxxx

Contact Phone Work
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xxx-xxx-xxxx

Contact Phone Mobile
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xxx-xxx-xxxx

Best Time to Contact Me(*)

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Note: No International Call Backs.
(*)
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