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APPOINTMENTS

Want to schedule an exam? Need some new contacts? Have questions for the doctor?

We would love to meet with you! Please fill out this form and we will contact you shortly. Thanks!


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Two GREAT LOCATIONS

We have two locations to serve you better. Visit us in Bexley, or Lancaster.


Appointment Request Form
Patient Name *
Patient Name
Patient DOB *
Patient DOB
Desired Location
Desired Appintment Date
Desired Appintment Date
Are you interested in a Contact Lens Examination? *
Please fill in your medical insurance provider.
Please fill in the member ID number listed on your medical insurance identification card.
Please fill in your vision insurance provider.
Please fill in the member ID number associated with your vision insurance. If you don't have one, skip this section.
Are you the primary member listed on the insurance policy? *
If you answered no to the previous question, please fill in the following:
Primary Name
Primary Name
Primary DOB
Primary DOB