Please fill in the form below to setup an appointment.

Reason for Appointment

Please provide a reason for your appointment. Details are stored securely and not sent by email.

Preferred Date & Times*

Please let us know when you would prefer to have your appointment. Our hours are listed on our location page.

Patient Type*

Please let us know if you are a new or existing patient.

Name*

First Last

Phone*

Email*

Date Of Birth*

Insurance

Please check off both boxes if you have medical insurance AND a vision plan.

Medical Insurance Name

Medical Insurance Member ID

Vision Plan Name

Vision Plan Member ID

Comments

Name

This field is for validation purposes and should be left unchanged.

Appointment Request Form

Wendy Waguespack, OD