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Schedule an appointment?

Give us a call at any one of our MyEyeDr. Offices today. New and returning patients can also submit a request for an appointment online by completing the form below. We'll do our best to accommodate your request and let you know about availability within 24 hours (or the next business day). If you're requesting an appointment for the same day or on a Sunday please call the office directly, so we can better assist your inquiry.

IF THIS IS AN EMERGENCY: Do NOT use this form if you are experiencing an eye injury or serious vision health complication. This is only for NON-emergency requests for vision care. If you have a serious eye problem, please call MyEyeDr. at 1-866-693-9336 during regular business hours or contact your personal physician immediately.

Preferred Day:
Preferred Time:
Preferred Office Location:  
Patient Status: New Patient
Returning Patient

Date of Last Exam:
Purpose of Visit: Eye Health Exam  

Please explain


Other

Please explain
Patient's First Name:
Patient's Last Name:
Patient's DOB (Month/Day):
Are you using an Internet deal for your exam and eyeglasses?:   Which one?
Are you using Vision Insurance?:
What type of insurance (Please select):

If "Other" Please Enter Name
Are you the policy holder?

If no, who is the policy holder (person's name)?
Your Relationship to Patient:
Your First Name:
Your Last Name:
E-Mail:
Daytime Phone Number: - - x
Mobile Phone Number: - - x
Best Time to Call:
Preferred Contact Method: