Request an Appointment

Save time and resources by scheduling your appointment below and we'll thank you for "going green" by giving you $5 gift card to Starbucks® or Jamba Juice® when you come in!

• Required

Title DR MISS MR MRS MS
First Name •
Last Name •
Email Address •
Home Address •
City •
State •
Zipcode/Postcode •
Home Phone Number •

Desired Date/Time •
Reason for Visit -- Please select -- Lasik Eye Irritation Routine Exam Glasses Contact Lenses •
Medical Insurance -- Please select -- Blue Shield Blue Cross United Health Care Pacificare Medicare Don't Know / Other •
Vision Benefit -- Please select -- Vision Service Plan Eyemed Superior Vision Safeguard MES Don't Know / Other
I Wear Correction For -- Please select -- Reading Distance All Situations
I Currently WearSoft Contacts
Gas Permeable Contacts
Glasses
I Am -- Please select -- Near Sighted Far Sighted Don't Know

Enter Word Verification in box below
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