Quality Family Eye Care - Clear Lake Optometry

Welcome to Clear Lake Optometry on-line appointment request system. To request an appointment, please enter the information requested and then click on the "Submit" button at the bottom of the page. We will contact you, usually within 2 business days with a proposed appointment date and time.

	First name:		Middle initial:
	Last name:
	Date of birth		Email:

	Daytime phone:	Area code:-
	Evening phone:	Area code:-

Please choose 2 appointment dates, in order of preference, that you prefer.

First choice:

Second choice:

	What time of day would you prefer? (check one)
	Morning Afternoon Either

	Have you ever been a patient at Clear Lake Optometry before? yes no
	If so, approximately when:

	Additional information that you wish to provide us:

	How would you like us to confirm your appointment?
	phone - preferred and fastest method of confirmation (be sure that you filled in the "phone #" field at the beginning of this form) e-mail (be sure that you filled in the "email" field at the beginning of this form)

Before submitting this appointment request with the button below, please re-read your entries to ensure that your information is accurate.

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	14 N 8TH ST \|\| Clear Lake, Iowa 50428 \|\| Located in T-K plaza Phone: (641) 357-2020 \|\| Fax: (641) 357-7149 \|\|
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