Appointment Request Form

Please note our office hours on the side of our website before choosing an appointment time. A member of our staff will contact you as soon as possible to confirm the first available date!

Please be advised your appointment time is not finalized until you receive confirmation from our staff. If you have not heard from our office within 24 hours please call.

Please fill in the form below to setup an appointment.
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*
Consent
By checking this box (or signing here), you are consenting to receive SMS text messages from Eastern Sierra Eyecare. Msg&data rates may apply. You may reply STOP to opt out of messages.
Terms and Conditions (Terms of Service)

Effective Date: December 5, 2024

By opting in to receive SMS messages from Eastern Sierra Eyecare (“we,” “us,” “our”), you agree to the following terms:
1. SMS Messaging Service
  
  By providing your phone number, you consent to receive SMS messages, including updates, promotions, and other relevant content.
2. Message Frequency
  
  You will receive up to 4 messages per month.
3. Message and Data Rates
  
  Message and data rates may apply based on your mobile carrier’s terms.
4. Privacy Policy
  
  Your information will be handled in accordance with our Privacy Policy, which can be viewed at https://www.easternsierraeyecare.com/privacy-policy/
5. Opt-Out Instructions
  
  You can opt out at any time by replying “STOP” to any SMS message. You may also contact us directly at https://www.easternsierraeyecare.com/contact-us/
6. Liability
  
  We are not responsible for any charges, errors, or delays in SMS delivery caused by your carrier or third-party service providers.
By opting in, you confirm that you are the owner or authorized user of the phone number provided and that you are at least 18 years old.
Email*
Best Time to be Reached for Confirmation*

: Hours

Minutes

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

Please be advised your appointment time is not finalized until you receive confirmation from our staff. If you have not heard from our office within 24 hours please call.

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