Request an Appointment

Basic form for clients to request an appointment with the practice.

Please keep in mind we might not be able to accommodate same-day appointment requests, but we will fit you into our schedule as soon as we have an opening. Please fill in the form below to set up an appointment.
Reason for Appointment
Please 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
Preferred Method of Contact*
- Phone
- Text
- Email
Date of Birth*
Vision Plan*
Please provide the vision insurance and member ID number to be used for the exam if any.
If the patient will be self pay, please just state "none."
Interested in Contact Lenses?*
- Yes
- No
Comments
CAPTCHA
Date
MM slash DD slash YYYY
Comments
This field is for validation purposes and should be left unchanged.

High Plains Vision Center