Appointment Request Form

If this is an emergency, do not contact us via email, please use our emergency contact information.

Complete the following form:

Please fill in the form below to setup an appointment.
Doctor
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*
SMS Opt-in
- Opt-in to Text Messages
By providing a telephone number and checking "Opt-in to Text Messages", I consent to be contacted by SMS text messages regarding customer care, account notifications, and delivery notifications. Reply STOP to opt-out of further messaging. Reply HELP for more information. Message frequency may vary. Message and data rates may apply. I agree with the Privacy Policy and SMS Terms and Conditions of Long Beach Vision Care.
Email*
Best Time to be Reached for Confirmation*

: Hours

Minutes

AM/PM
Comments
Untitled
- First Choice
- Second Choice
- Third Choice
Comments
This field is for validation purposes and should be left unchanged.

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