New Patients

We are NOT accepting new patients at this time. We have limited space for the following exceptions:

Your Ophthalmologist specifically referred you to our office
You are an immediate family member or in the same household as a current patient of our office.
You have been examined in the last decade by Dr. Lesli Handmacher or Kensington Optometry (Dr. Russell Cotteral & Assoc.)

New patients that qualify can fill out the form below and we will welcome you to the practice as availability permits. Please note that we are booking 4-8 weeks in advance.

Name

First Name

Last Name

Date of Birth

YYYY

Best Email

Best Phone Number

(###)

###

####

Text OK?

Yes

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Have you been referred by your Ophthalmologist? Please let us know whom.

Have you been a patient of Dr. Nadia Samii, Dr. Lesli Handmacher, or Dr. Russell Cotteral in the past?

Are you being referred by a family member or household member that is currently our patient? Please let us know whom.

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

Insurance

Please indicate the Vision Insurance Coverage you currently have

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

Tell us about what we can do for you

Are you experiencing any vision or eye health concerns? (If the concern is a sudden onset of vision loss, double vision, or eye pain that has not resolved please seek immediate attention from an Emergency Department or call 911.)

Do you have a medical condition that requires routine monitoring of your eye health?

What year was your last eye exam? Which practice/doctor performed the exam?

What year were your last glasses made? Which practice/optician built your last glasses?

Will any other family members be needing our services in the near future? Please list their ages.

New Patients

Your Two Eyes Optometry

Contact

Messages

Office Hours