Appointment Request Form

If this is an emergency, do not contact us via email.

To request your next appointment with Tri City Eye Care, please complete the form below and let us know the most convenient time and date for you. Please don’t forget to include accurate contact details so we can follow up with you to finalize your request.

Appointment Request Form

Basic form for clients to request an appointment with the practice.

Please fill in the form below to setup an appointment.
Reason for Appointment
Please provide a reason for your appointment. Details are stored securely and not sent by email.
Preferred Date & Times*
Please let us know when you would prefer to have your appointment. Our hours are listed on our location page.
Patient Type*
- New patient
- Returning patient
Please let us know if you are a new or existing patient.
Name*
First Last
Phone*
Email*
Best Time to be Reached for Confirmation*

:

AM/PM
Comments
Name
This field is for validation purposes and should be left unchanged.