Kremer Eye Center™ | Schedule a Consultation

Appointment Request Form

Ready to see the world as you always imagined? Take the first step by scheduling an appointment with one of our specialists. Initial screenings and medical evaluations can be performed at one of our many convenient locations throughout the region.

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Contact Information

Salutation: *

First Name: *

Middle Name:

Last Name: *

Home Address 1: *

Home Address 2:

City: *

State: *

Zip Code: *

Date of Birth: *

Email: *

Daytime Phone: *

Appointment Information

Appointment For: *

Location: *

Have you had previous eye surgery?: *

Yes

Depending on the type of eye surgery you had previously, you may require a dilated exam and more testing than a typical new appointment permits. A patient care representative will be in touch to review this with you further, so that we can be sure to schedule the appropriate type of evaluation for you.

Date Desired: *

Time: *

How did you hear about Kremer Eye Center? : *

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