Appointment Request

1
Financial Disclosure* This field is required.As an open-access optometry practice, we focus on providing you with direct, personalized care. All services are out-of-pocket, with payment due at the time of your visit. For your convenience, we can electronically submit a paperless claim to most insurance providers, aiming to help you get reimbursed faster. Please confirm your understanding by selecting "AGREE" to continue, or click "Call Our Office" for any questions regarding your benefits or our process before proceeding.
AGREE Call Our Office
2
Please call or text our office

949-733-1400
3
Patient's Name* This field is required.
First Name
Last Name
4
Phone Number* This field is required.By submitting a cell phone number you agree to allow us to text message or call you regarding your appointment.
Area Code
Phone Number
5
Are you a new patient?
YESNO
6
I'm interested in...* This field is required.Please select at least one.
Glasses
Contacts
Vision Therapy
7
Please select 2 days that work best for your appointment
Please Select
Please Select
Monday
Tuesday
Thursday
Friday
First choice of day
Please Select
Please Select
Monday
Tuesday
Thursday
Friday
Second choice
Morning
Afternoon
Time of day that works best for you.
Should be Empty: