Appointment Request Form

Please fill in the form below to setup an appointment. Please note that this is an appointment request only. Our office will call or email you back to confirm your request. Thank-you.

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 when you would prefer to have your appointment. Our hours are listed on our location page.

Patient Type*

New patient
Returning patient

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

Name*

First Last

Phone*

Email*

Best Time to be Reached for Confirmation*

:

Comments

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

Eye Trends
Clear Lake

Appointment Request Form

Eye Trends Clear Lake