Appointment Request Form We are currently scheduling several weeks out for eye exams. If you have a more urgent need or are requesting an after 4:00pm appointment please call the office at 937-568-7200 so we can more easily accommodate your schedule. Please fill in the form below to setup an appointment.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 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 CommentsCommentsThis field is for validation purposes and should be left unchanged. Δ
