Want to schedule an appointment? Don't have the time to call? This quick Email form will get the process started for you. Just fill out
the form and submit it. We'll get back to you with a quick response to confirm your appointment. Thanks for coming in for a visit.
First Name
Middle initial
Last name
Date of birth
Email
Daytime phone
Please choose 2 appointment dates, in order of preference, that you prefer.
Choice 1:
Choice 2:
What time of day would you prefer? (check one)
Morning
Afternoon
Either
Have you ever been a patient at
American Vision at the Court before?
yes
no
If so, approximately when:
Reason for your visit and/or
additional information that you wish to provide us:
How would you like us to confirm your appointment?
phone - preferred and fastest method of confirmation (be sure that you filled in the "phone #" field at the beginning of this form) Email
(be sure that you filled in the "email" field at the beginning of this form)
Before submitting this appointment request with the button below, please re-read
your entries to ensure that your information is accurate and read the following privacy statement.
The information you supply via this appointment form is considered strictly confidential and
will never willingly be shared with anyone without your explicit permission. If you deem the information we ask
for to be sensitive, the only way to ensure its absolute security is to discuss it with the doctor face-to-face.
We encourage you to do so by requesting an appointment by phone.
