Appointment Request Form

If you have an urgent or emergency request, please call us at 214-382-3061, instead of using this request form. emergency contact information

To request your next annual exam, please complete the form below and let us know the most convenient time and date for you. Please include accurate contact details so we can follow up with you to finalize your request. On line appointment request are answered Monday-Friday during our regular business hours.

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*
Email*
Best Time to be Reached for Confirmation*

: HH

MM
Comments
Name of Vision or Medical Insurance
Name
This field is for validation purposes and should be left unchanged.

Appointment Request Form

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Las Colinas Vision Center

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214-382-3061

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Las Colinas Vision Center