Appointment Request Form Please fill in the form below to setup an appointment.Patient Type* New patient Returning patient Please let us know if you are a new or existing patient.This exam is for: A Child An Adult Latest in Child Eye Care Is your child's vision getting worse? If your child is myopic, showing signs of progression, or is at risk of myopia progression, Our eye doctor will discuss myopia management at your child upcoming eye exam. Feel free to contact us at 304-766-2220 before your eye exam to learn more about this service or browse our website for further resources. Reason for Appointment* Child is getting more nearsighted each year. Learn More Here Myopia Management or Control Ortho-K or CRT or GVSS (Vision Correction) Vision Therapy (Eye Therapy) Reading & Learning Problems in Children Lazy Eye (Amblyopia) or an Eye Turn (Strabismus) Child with Special Needs Attention or Concentration Problems Regular Eye Exam Contact Lens Exam Other Choose from any of the following options. Reason for Appointment* Tearing or watery eyes Sensitive or rubbing eyes Eye Conditions and Diseases Improve Visual Abilities for Athletes Vision Therapy for Adults Regular Eye Exam Contact Lens Exam Other Please Specify* Preferred Date & Times*Please let us know when you would prefer to have your appointment. Our hours are listed on our location page.Name* First Last Phone*Email* Name of Vision Insurance Company* Medical Insurance Company* Patient Date of Birth* MM slash DD slash YYYY Last 4 SSN* How did you find us?*Friend/FamilyGoogle Search/WebsiteSocial MediaDoctor ReferralOtherPlease Specify* CommentsCommentsThis field is for validation purposes and should be left unchanged.