Appointment Request

Name: Laser Eye Institute
Price range: $$$

Complete the form below to request an appointment at Laser Eye Institute. Please note that after you submit the form our team will contact you to confirm your appointment or suggest alternate appointment dates and times if your selected time is not available.

Appointments are not valid until you receive confirmation from our team.

Contact Information
First Name*
Last Name*
Phone Number*
Email Address*
Preferred Contact Method*
Preferred Contact Method*
- Phone
- Email
Birthday*
MM
DD
YYYY
Appointment Information
Are You A New Patient?*
What Best Describes Your Appointment?*
Medical Insurance Provider
Vision Insurance Provider
Preferred Date*
Date Format: MM slash DD slash YYYY
Preferred Time*
Additional Notes

Appointment Request

Contact Information

Appointment Information