First name
Last name
Email
Phone Number
This is the number we will call you from 602-955-1000 which will show up on your caller id
Are you an existing patient?
Yes
No
Date of Birth
Month
Day
Year
Date of Birth
To select your birth year
- click the calendar icon then click/tap "January 1970" between the arrows
01
/
01
/
1970
What service are you interested in?
Please select
Eye Exam
Cataracts
Glaucoma or Cornea or Retina
Dry Eye
Cosmetics
LASIK or PRK or ICL or Refractive Lens Exchange
No Service
Other Service
Please select
How can we help you?
Please select
Billing
Contacts/Glasses Prescription
Medical Prescription
My Upcoming Appointment (confirm, cancel, question)
Scheduling an Appointment
Patient Portal
Other
Please select
Please choose one of the following:
Please select
Business Inquiry
Media Inquiry
Other
Please select
Clinic Location
This is very important, please choose carefully to have you submission properly routed. If you are existing patient, please choose the location you regularly visit
Please select
Mesa Baseline, AZ
Phoenix, AZ
Mesa Southern, AZ
Chandler, AZ
Sun City, AZ
Surprise, AZ
Goodyear, AZ
Glendale, AZ
Scottsdale, AZ
Green Valley, AZ
Tucson Wetmore, AZ
Tucson Oracle Rd (Oro Valley), AZ
Tucson, AZ (5th Street)
Flagstaff, AZ
Sedona, AZ
Show Low, AZ
Globe, AZ
Lake Havasu, AZ (40 Capri Blvd)
Lake Havasu, AZ (383 Lake Havasu Ave)
Parker, AZ
Blythe, AZ
Safford, AZ
Lakeside, AZ
Please select
Include any additional information so our clinic staff can best help you:
Include any details about the best time of day to reach you
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