Schedule an Appointment

Welcome to our online appointment scheduling. We’ve made it easy for you to request an appointment by filling out this quick and easy form.  Please keep the following in mind:

• Please do not request a “same day appointment” via this website.
• Please do not include sensitive medical information on this appointment request that you would not normally feel comfortable sending over email as this is not a secure contact form.

This form is for a “request” only. You do not have an actual appointment until you receive either a telephone call or an email from one of our schedulers to confirm your appointment details. We appreciate your understanding.

1. Are you a…
2. Current Patient
   New Patient
3. First Name(required)
4. Last Name
5. Address
6. City
7. State
8. Zip Code
9. Phone (day)
10. Phone (evening)
11. Best time to call
12. Email address(valid email required)
13. Which day do you prefer?
14. Monday
    Tuesday
    Wednesday
    Thursday
    Friday
15. What time do you prefer?
16. Morning
    Afternoon
17. Which office location do you prefer?
18. Fort Myers
    Cape Coral
    Punta Gorda
    Lehigh Acres
    Naples
19. Reason for the appointment?
20. Routine Eye Exam
    Cataract Evaluation
    Complimentary LASIK Screening
    Other
21. If other, explain:
22. Type of insurance
23. Message

 

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