Appointment Request Form Please fill in the form below to setup an appointment.Reason for AppointmentPlease provide a reason for your appointment. Details are stored securely.Preferred Date* Preferred Time*8am-10am10am-12pm2pm- 3:30pm3:30pm - closePreferred Doctor*>>Select>>Dr. DugganDr. ClarkNo PreferencePatient Name* First Last Vision InsurancePlease bring all insurance cards with you to your appointment.Vision Insurance NamePrimary Member's Name First Last Member ID NumberPrimary Member's Date of Birth Health InsurancePlease bring all insurance cards with you to your appointment.Health Insurance NamePrimary Member's Name First Last Member ID NumberPrimary Member's Date of Birth Patient or GuardianPhone*Email* Best Time to be Reached for Confirmation*8am-10am10am-12pm2pm- 3:30pm3:30pm - closeCommentsOnce you submit an online appointment request, our office staff will notify you of available appointment times by text, email, and/or by phone. It’s that simple!CommentsThis field is for validation purposes and should be left unchanged.