Schedule an Appointment Appointment Request Form Basic form for clients to request an appointment with the practice. Please fill in the form below to setup an appointment.Reason for Appointment* Blurry Vision Routine Annual Eye Exam Eye Emergency (pain, injury) Contact Lens Exam Broken Glasses Referred by Pediatrician Please provide a reason for your appointment. Select all that apply. Details are stored securely and not sent by email.Preferred Date/Time*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.Patient Name* First Last Phone*Email Insurance Name and Member ID#: Please list both your Vision Plan and Medical Insurance information.Preferred Doctor Dr. Lianette Laria Dr. Vicky Fischer Dr. Diana Perez Dr. Claudia Bello Dr. Aurora Perez First Available/No Preference Preferred Office Location* Flagler Office: 8220 West Flagler Street Bird Office: 5785 Bird Road, Suite B First Available/No Preference In which location would you prefer to be seen?Preferred Contact Method* Text Message Phone Call Email How would you like us to get in touch with you?CommentsNameThis field is for validation purposes and should be left unchanged.