Appointment Request Form Don’t have time? Give us a call! Call 714-421-4636 If this is an emergency, do not contact us via email, please use our emergency contact information. Complete the following form: Please fill in the form below to setup an appointment.Reason For Appointment* Comprehensive Eye Exam Contact Lens Exam Pediatric Eye Exam Medical Eye Exam Dry Eye Exam Intense Pulsed Light (IPL) Consult Specialty Contact Lenses Consult Scleral Lens Consult Keratoconus Consult Issues because of Lasik Myopia Management / Control Ortho-K / Orthokeratology Color Blindness / Color Vision Testing NeuroLens Consultation Other (You can choose more than one)Please share the other reason(s)HiddenReason for AppointmentPlease provide a reason for your appointment. Details are stored securely and not sent by email.Preferred Date* MM slash DD slash YYYY Preferred 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 : Hours Minutes AM PM AM/PM CommentsPhoneThis field is for validation purposes and should be left unchanged.