Appointment Form for OrthoK and Gentle Vision Shaping System Consultation

Reason for Appointment

Please provide a reason for your appointment. Details are stored securely and not sent by email.

Preferred date and time*

Please let us know when you would prefer to have your appointment. Our hours are listed on our location page.

Patient type*

Name*

First Last

Phone*

Email*

Does the patient currently wear glasses and/or contact lenses?

Best Time to be Reached for Confirmation*

: HH

MM

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