Appointment Request Form Please fill in the form below to setup an appointment.Patient Type* New patient Returning patient Please let us know if you are a new or existing patient.This exam is for:* A Child An Adult Our practice specializes in Myopia Management for children. Nearsightedness / myopia is one of the leading causes of eye disease in adults, but myopia management can slow down myopic progression in your child and help prevent glaucoma, macular degeneration, etc. If you haven't heard about myopia management, please click here here to learn more about it. If it is relevant for your child, our eye doctor will introduce you to myopia management at the eye exam. Feel free to contact us at 631-286-4014 before your child's eye exam to learn more about this service or browse our website for further information. During your exam, would you be interested in hearing about controlling nearsightedness progression?* Yes Not at this time Reason for Appointment* Child is getting more nearsighted each year. Learn More Here Myopia Management or Control Ortho-K or CRT or GVSS (Vision Correction) Vision Therapy (Eye Therapy) Reading & Learning Problems in Children Lazy Eye (Amblyopia) or an Eye Turn (Strabismus) Child with Special Needs Attention or Concentration Problems Regular Eye Exam Contact Lens Exam Other Choose from any of the following options.Reason for Appointment* Tearing or watery eyes Sensitive or rubbing eyes High Astigmatism or High Prescription Keratoconus or Irregular Cornea Poor vision wearing contacts or glasses. Safe alternative to LASIK w/o surgery Ortho-K (Vision Correction) Eye Conditions and Diseases Headaches & Migraines Dizziness, Vertigo, Poor Balance Attention or Concentration Problems Post concussion, head trauma, stroke or brain injury Improve Visual Abilities for Athletes Vision Therapy for Adults Regular Eye Exam Contact Lens Exam Other Please Specify* Please Specify* HiddenReason for AppointmentPlease provide a reason for your appointment. Details are stored securely and not sent by email.Preferred Date & TimesPlease let us know when you would prefer to have your appointment. Our hours are listed on our location page.Name* First Last Phone*Email* HiddenBest Time to be Reached for Confirmation* : Hours Minutes AM PM Vision Coverage* Please note: Vision Coverage is usually not the same as your Health Insurance (some exceptions include Fidelis and Health First). If you are not sure what Vision Coverage you have, we recommend you contact your Human Resources Department or call your Health Insurance Company to find out what the vision rider is.Health Insurance* How did you find us?*Friend/FamilyGoogle Search/WebsiteSocial MediaDoctor ReferralOtherPlease Specify* Please Specify* CommentsCAPTCHAPhoneThis field is for validation purposes and should be left unchanged.