MedNet-Sites by MedNet Technologies

Please contact our office or complete the form below to schedule an appointment.  We are happy to answer any questions you may have via telephone or e-mail.  If you have a preference, please indicate this on the form below.  This information will be promptly handled by the appropriate individual within our office.

Please Note - E-Mail is not an emergency means of contacting our office.

*Please respond to the following required fields

Your Name
*
Street Address
Address 2   (Suite or PO Box)
City
State         Zip Code
       
Country
Phone
Ext. or Direct #
*
Fax
Age
E-Mail Address
*

Are you currently a patient: Yes No

If not, how did you hear about our practice: 

Do You wear Glasses or Contact Lenses: Yes No

If yes,

Would you like to schedule an appointment?Yes No

Please provide us with information about when you would like an appointment. We will e-mail you with an appointment confirmation.

Month of Preferred Time Preferred Day
Morning
Afternoon
Evening

  

Use the space below for your questions & comments:

   

     

  
 

 

 

Copyright © 2001- 2002 Advanced Vision & Laser Care, and MedNet Technologies, Inc. All Rights Reserved.
 This site is optimized for a display setting of 800 by 600 pixels, or greater.

MedNet-Sites by MedNet Technologies

MedNet-Sites™ - Powered by MedNet Technologies, Inc.