Request an Appointment

At Eye Therapy Vision Rehabilitation Center, we provide the highest quality service to all our patients. Use the form below to request your appointment. Please indicate your preferred date and time. Please note that we will reach out to you first to confirm your appointment or to provide you with an alternative date. You may also call us to request an appointment. Thank you!​​​​​​​

Reason for Appointment*

Preferred Date & Time*

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

Patient Type

Please let us know if you are a new or existing patient.

Patient Contact Information