Children's Eye Care — Request An Appointment

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Request An Appointment

Fill out and submit this quick and easy appointment request form and we'll contact you to confirm your preferred appointment or to help you choose the most convenient alternate if your requested appointment time and date is unavailable. Please complete all fields (parent/guardian name is not required if patient is over 18).

Patient's First Name

Patient's Last Name

Patient's Date of Birth

Parent or Guardian's First Name

Parent or Guardian's Last Name

Street Address

City

State

Zipcode

Country

Phone Number

Secondary Phone Number

Email Address

Preferred Appointment Date

Preferred Appointment Time
Morning Afternoon

OFFICE FORMS FOR YOUR APPOINTMENT

Below are the forms that we need to have in your file. Click each link to download the file prior to your first visit with us. Fill out each form at home to save time during the check-in process. Please arrive at least 15 minutes in advance of your appointment if you would like to fill out the forms at the office.

We will contact you to confirm your preferred appointment or to help you choose the most convenient alternate if your requested appointment time and date is unavailable.