Request Visual Performance Evaluation

Use this form to request an initial evaluation. While we will do our best to accommodate your requested day and time, please note, your appointment is not fully booked until you get a confirmation from us!

Patient's Name(Required)

Age(Required)

Grade

Parent/Guardian's Name(Required)

Address

Street Address Address Line 2 City State ZIP Code

Phone(Required)

Preferred Appointment Day(Required)

Appointments only available on Tuesday, Wednesday and Thursday afternoons.

Tuesday

Wednesday

Thursday

Notes to Doctor

Please provide any information that may be helpful. Please do not submit any Protected Health Information (PHI).

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