Name *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Best Phone Number *

(###)

###

####

Text OK?

Yes

No

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

I currently wear...

Dr Samii will work to address your current visual needs, so let us know what you're using now. Check all that apply:

Glasses

Contacts

Preferred Appt Times

Looking at the month ahead, which of these days and times are likely to work for you to come in to see Dr Samii and her team?

Tuesday or Thursday before 1pm

Wednesday or Friday before 1pm

Tuesday or Thursday after 2pm

Wednesday or Friday after 2pm