Scleral and Hard-to-fit-Contact Lens Appointment Request

Scleral Lens Appointment Request Form

Please fill in the form below to request an appointment. This is only a request for an appointment, our office will contact you via text and/or email to confirm it has been scheduled

Type of Appointment
This appointment form is for Scleral Contact Lenses and other specialty contact lenses. or Vision Therapy, click Here. For General Eye Care, click Here.
Patient Type*
- New Patient
- Returning Patient
Reason For Appointment
Please provide a reason for your appointment. Details are stored securely and not sent by email.
Preferred Date and Times*
Please let us know when you would prefer to have your appointment. Our hours are listed on our Contact Us page.
Name*
First Last
Phone*
Email*
Best Time to be Reached for Confirmation

Hours :

Minutes
Name
This field is for validation purposes and should be left unchanged.