Complete the form below and one of our helpful staff will be in contact with you.

Contact Information
Name:
Email Address:
Phone:
Type of Appointment
Eye Exam
Contact Lenses
Eye Problem(s)
List 3 dates and time in order you wish to make an appointment
First Choice	ex: 9/12/03 2:30pm
Second Choice
Third Choice
Office Location	(Lee's Summit or Lenexa)
Please add any comments you feel important to your visit.