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

Phone

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

Appointment Request Form

Wendy Waguespack, OD