Personalized Family Eye Care
4 ONLINE_APPOINTMENT_SCHEDULING 4 Homepage 4 About Us 4 Glasses 4 Frames 4 Rx Lenses 4 Sunglasses 4 Sunglasses Lenses 4 Coatings 4 Contact Lenses 4 LASIK 4 Insurance Plans 4 Optical Terms 4 F.A.Q. 4 Web Specials 4 HIPAA Privacy 4 Contact Us 4 Forms 4 Order Contact Lenses 4 Make Appointment 4 Eye Exams 4 Other Links 4 Office_Pictures			Make Appointment Patient information: Name: required Home Phone: required Work Phone: Ext Email Address: required Reason for the Examination: Please check all that apply: Comprehensive Eye Exam Injury Blurred Vision Cataract Contact Lenses Red Eye Itching Tearing Laser Vision Evaluation Infection Headache Double Vision Loss of Vision Pain Glaucoma Other Please list any other reasons: What vision insurance will we be billing for you: Office Hours Monday 9am to 5:30pm Tuesday 9am to 5:30pm Wednesday 9am to 5:30pm Thursday 9am to 5:30pm Friday 9am to 5:30pm Saturday 9am to 1pm When would you like to book your appointment? My first choice is: Month Day Date Time January February March April May June July August September October November December * Monday Tuesday Wednesday Thursday Friday * 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 * Morning Early Afternoon Late Afternoon Early Evening Late Evening * My second choice is: Month Day Date Time January February March April May June July August September October November December * Monday Tuesday Wednesday Thursday Friday * 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 * Morning Early Afternoon Late Afternoon Early Evening Late Evening * Please confirm my appointment via: Email Phone
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