Request an Appointment do or do not , there is no try check that box Full Name Email Phone Are you currently a patient with us? Yes, I'm a current patient No I'm a new patient Reason for Appointment? Abnormal/Blurry Vision Double Vision Eye Pain or Loss of Vision Dry Eye Treatment Nearsightedness Farsightedness Astigmatism Age-related Vision Loss Keratoconus Glaucoma Macular Degeneration Cataract Surgery Refractive Surgery/LASIK Corneal Transplants Eyelid Surgery Glasses Prescription Contact Lens Exam/Prescription Please enter 3 preferred dates for your appointment Desired appointment date? How did you hear about our practice? Google/Internet Search Social Media Review Website Other Internet Source Referral (Friend, family, colleague, team Member Advertisement Our Location/Signage Phonebook Other Preferred Method of Contact Phone Email Text/sms Was our website helpful/informative? Yes No Comments: Communications through our website or via email are not encrypted and are not necessarily secure. Use of the internet or email is for your convenience only, and by using them, you assume the risk of unauthorized use.