Please use this form for general information purposes only. DO NOT send personal health information through this form. Specific patient care must be addressed during your appointment.Please complete the following form to request an appointment. Please also note that availability will vary depending on your request. This is NOT a confirmed appointment time until a member of our staff calls to confirm the date, time, and eligibility of insurance. Thank you!Name* Phone* Email* Preferred Date* MM slash DD slash YYYY Preferred TimeMorningAfternoonEveningVision Insurance Type Diabetic Yes No Nature of VisitCAPTCHAEmailThis field is for validation purposes and should be left unchanged.