Request an appointment

If you have an eye emergency, please do not use this form. Instead, call our office during regular hours 804.748.6983 or visit the nearest emergency room.  

Name *
Name
Date of Birth *
Date of Birth *
Phone *
Phone
We may contact you by phone to most promptly schedule your appointment.
Reason for appointment
Do you have insurance? (Insurance not required to schedule appointment)
This enables us to expedite your appointment request when we contact you.
Requested appointment time (please select all that apply)
Last appointment of day is 45 mins before closing.

* denotes required field.

Thank you for contacting us. We monitor email throughout the workday. If your matter is more urgent, the fastest way to reach us is to call us at 804.748.6983.