Stirling Eyecare & LASIK Center
Appointment Request

Please fill out form below to make appointment (please allow 24 hours for response) or call us for faster service.

Patient information:

Patient name:

Home phone:

Work phone:

Email address:

Is this your first visit?

What is the reason for appointment?

Routine eye exam

Specific concerns (please state below)

Concerns, if any:

Please enter 3 preferences of day and/or time (eg - Mon morning, Mon 10am, 10am any weekday, 2pm this weekend, etc)

How do you prefer to be contacted for confirmation?

Phone