Appointment Request Form

Please fill in the form below to setup an appointment.

Reason for Appointment

Please provide a reason for your appointment. Details are stored securely and not sent by email.

Preferred Date & Times*

Please let us know your preferred appointment time and date and we will do our best to accommodate your request. Our appointment times are: Mondays 9am-5pm, Tuesdays 10am-6:30pm, Wednesday 12:30pm-5pm, Thursdays 10am - 6:30pm, Fridays 9am-12:30pm.

Patient Type*

New patient
Returning patient

Please let us know if you are a new or existing patient.

Name*

First Last

Phone*

Email*

Comments

Please provide Vision Insurance information if you have it.

Phone

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

Appointment Request Form

FocusVision

Call today and make your appointment: 303-776-1620