Request Appointment

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!

Your Name

Your Date of Birth

Are you a new patient to our office?

Yes No

Your telephone number

Your email address

Patient Name (if different from you)

Patient Date of Birth

Desired Appointment Date

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.

What is the reason you are requesting the appointment?

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

Upload Files Use this link to submit files or photos that may be helpful to us. Examples include copies/photos of your insurance card, medications list, photo(s) of the reason you are requesting appointment, etc.

Add file

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.

Request Appointment

Ryan Losh, O.D.

Losh Optomery LLC