Schedule Your Appointment
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1. Type Your Name
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2. Type Your Email Address
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3. Type In Your Phone Number
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4. Type In Your Daytime Phone Number
5. Type In Your Fax Number
6. Type of Appointment:
Medical Visit For Eye Diseases
Annual Check-Up
Non-Surgical Vision Correction
Eye Glass / Contact Lens Exam
Other
7. Preferred Day for Appointment:
Monday
Tuesday
Wednesday
Thursday
Saturday
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8. Preferred Time of Appointment:
Morning
Afternoon
No Preference
9. If you have any special circumstances
we need to be aware of as we schedule
your appointment, please tell us here:
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Indicates Response Required