Appointment Request Form

Please fill in the form below, and we will contact you to set up an appointment. If your request is time-sensitive, do not contact us via email. This page is only checked during regular business hours. If you have questions regarding your medical care or have an eye emergency, call us at 402-552-2020.
Location*
- 43rd & Dodge
- 135th & California
- 72nd & Giles
- 181st & Q
- Council Bluffs
- Fremont
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*

: Hours

Minutes

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