Request form

Please be aware that this is a REQUEST for an appointment and not
an actual booked appointment. A member of our team will contact you
shortly to CONFIRM or RESCHEDULE your original request based on availability.

You can only fill out this form if you are not wearing Ortho-K lenses.
Please call us at 408-777-8771 during our office hours to schedule an appointment if you are wearing Ortho-K lenses.

Click submit and you hereby give consent to sign this document electronically.

Sending data