Request Appointment - My Eyes Optometry

IMPORTANT – PLEASE READ BEFORE SUBMITTING AN APPOINTMENT REQUEST

Please fill out the form below to REQUEST an appointment. Appointments are not scheduled until our staff calls you to confirm appointment details.

Important: Should you desire an appointment within the next three business days, please call our office rather than submit an online request. Please note that the date and time you requested may not be available. We will do our best to accommodate your request. We will contact you to confirm your actual appointment details. Please note that our offices are not open on weekends.

First Name*
Last Name*
Exam Type Wanted*
Select Office*
Patient Status*
- New Patient
- Current Patient
Preferred Appointment Date
Date Format: MM slash DD slash YYYY

If you desire an appointment within the next three business days, please CALL 919-639-2020 rather than submit an online request.
Preferred Times
Birth Date*
Date Format: MM slash DD slash YYYY
Phone*
Cell
Email*
Notes