Appointment Request Form

In an emergency please call the office at 480-967-4910 for instructions.

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 note: Saturday appointments (one a month subject to availability) require a credit card on file, a no-show fee of $75 will be charged in the event of a cancelation of less that 24 hours. Appointments after 4:20pm are Tuesdays only and book up very quickly, please expect these appointments to be about a month out. 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
This field is for validation purposes and should be left unchanged.

If you have not heard from us within 48 hrs, please call our office at: Phone 480-967-4910

Tempe Eyecare Associates