Appointment Request Form If you are interested in a free consultation, please fill out the form below & include in the comments section that you would like a consultation.Reason For AppointmentVision Therapy (Amblyopia, Learning problems, etc.)Therapy after Brain Injury / ConcussionOrthokeratologyMyopia ManagementSports Vision TrainingOtherOther Reason for AppointmentPlease provide a reason for your appointment. Details are stored securely and not sent by email.HiddenPreferred 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 Name* First Last Phone*Email* HiddenBest Time to be Reached for Confirmation : Hours Minutes AM PM Have any additional comments? Yes No CommentsNameThis field is for validation purposes and should be left unchanged.