Request Appointment

Please correct the errors described below.

Use this form to request an appointment with us. While we will do our best to accommodate your requested day and time, please note, your appointment is not fully booked until you get a confirmation from us!

Select desired time for appointment on Monday, Wednesday, or Thursday
Select desired time for Tuesday appointment.

Please select your desired date & time above. Note: If you are requesting a Tuesday appointment, please use the "Tue Time" drop down, otherwise use the "Mon, Wed, Thu Time" option.

Please provide a short description of the reason you are requesting the appointment -- i.e. routine exam, contact lenses, sore/red eye, etc.
    Please upload a file

    Note: The information on this form will be encrypted and sent to Losh Optometry in a secure and HIPAA compliant manner.

    Your information will be encrypted.