Appointment Request Form Reason for Appointment Eye Exam Medical Exam Contact Lens Exam Cataract Surgery Consult LASIK Consult Other Details are stored securely and not sent by email.Patient Type*New patientReturning patientPreferred Date* Date Format: MM slash DD slash YYYY Preferred Time*MorningAfternoonName* First Last Phone*Email* CommentsCommentsThis field is for validation purposes and should be left unchanged.