Appointment Request Page Appointment Request Form Basic form for clients to request an appointment with the practice. Step 1 of 3 33% Please fill in the form below to setup an appointment.Type of AppointmentInfant or Child ExamAdult ExamMyopia Control EvaluationVision Therapy EvaluationSports Vision EvaluationOrthokeratology ExamMedical Eye CareType of AppointmentLocation*Bright Eyes Family Vision CareBright Eyes KidsChoose between Bright Eyes Family Vision (Adults and Kids) and Bright Eyes Kids (Pediatric only). The address of both locations is listed on our Contact Us page.Reason for AppointmentPlease 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 Contact Us page.Patient Type* New patient Returning patient Patient's Name* First Last Parent's Name (if applicable) First Last Phone*Email* Best Time to be Reached for Confirmation* : AM PM AM/PM PhoneThis field is for validation purposes and should be left unchanged.