Ready to Schedule Your Appointment?
Simply fill out the form below, and one of our team members will contact you as soon as possible to finalize the details and get your appointment scheduled!
Patient's Name
*
First Name
Last Name
Address
*
Parent/Guardian's Name (if applicable)
First Name
Last Name
What type of appointment did you want to schedule?
*
Eye exam-existing patient
Eye exam-new patient (welcome!)
Other
Is there a specific doctor, date, or time that you would like us to look for?
Which location would you like to schedule your appointment at?
*
Westerville office: 185 South State Street
The Solution Center (pediatric office): 937 Polaris Woods Blvd
Johnstown Office: 39 South Main Street
Lewis Center office (in the Mount Carmel Fitness Center): 7100 Graphics Way
How would you like us to contact you to schedule this appointment?
*
Text
Email
Phone call
Email
*
example@example.com
Phone Number
*
If you would selected "Text Me," please provide a cell phone number that can receive text messages.
Date of Birth
*
-
Month
-
Day
Year
Date
Gender
Please Select
Female
Male
Insurance Type (If self pay type "cash")
*
If you have a vision insurance, please list the name and date of birth of the primary insurance cardholder, so we can ensure everything is ready for your appointment.
Submit
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