Appointment Request Form Please fill in the form below to setup an appointment. THIS FORM IS NOT TO BE USED TO REQUEST AN EYE EMERGENCY APPOINTMENT - Please call our office instead for any urgent requestName* First Last Age*Patient Type* New patient Returning patient Please let us know if you are a new or existing patient.Phone*Email* Preferred Method of Contact* Phone Email DoctorFirst AvailableDr. LazarusDr. SimpsonDr. BrownDr. HatfieldPreferred Date & Times*Please let us know when you would prefer to have your appointment. Our hours are listed on our location page.Would you like to request any additional appointments for other family members?* Yes No Enter Names and AgesComments/Reason for Examination Request*Please provide a reason for your appointment. Details are stored securely and not sent by email.UntitledFirst ChoiceSecond ChoiceThird ChoiceCommentsThis field is for validation purposes and should be left unchanged.