Subject                      (choose one) Appointments Billing Lasik information Optical Contact lenses Medication renewal Other

               Your last name             

               Your first name        

               Daytime phone #     

               Your date of birth    

               Your chart number   (for billing questions)

                        For medication renewals provide the name and phone # of your pharmacy

                 Your request/question will processed as soon as possible. 

If you need immediate assistance please call the office directly. This form will be sent to the office via fax or E-mail. Information which you deem to be confidential should not be submitted.