Online Appointment Request

Appointment Request

Please fill out the details below to submit a new appointment request. One of our scheduling agents will contact you within 48 hours.
DISCLAIMER: If you are experiencing a medical emergency, please call 9-1-1. This form is for appointment requests only.
Full Name*

First NameLast Name
Phone Number*
Format: (000) 000-0000.
Email*
example@example.com
Phone - voiceTextEmail
New PatientExisting Patient
La QuintaPalm DesertYucca Valley
No health or eye issues; yearly routine exam. I would like an exam to get a glasses or contacts prescription and/or assess the overall health of my eyes. I do not need to discuss or address any current eye issue such as cataracts, dry eyes, diabetes, etc.Eye Problem. I am finding care for a new or previously diagnosed eye issue.Something else
Check my vision and/or eye healthI need an updated prescription for glasses/contactsI would like to get contacts for the first time
Eye RednessEyelid ProblemDry EyeFlashes and FloatersEye PainSudden loss of visionAllergic Eye ProblemsGlaucomaCataractsI am looking for care for another previous diagnosed conditionI want to see someone to discuss my needsSomething else
What is the main issue you want addressed?*
YesNo
Which doctor referred you?*
Doctor who referred you to have your eyes examined.
Select your preferred appointment date (Please note: date and time is not guaranteed to be available. We will call to confirm your appointment date and time)*

MonthDayYear
Appointment Date Requested
Select a preferred time:*
How did you hear about us?*
Other notes:
Should be Empty: