Optima Optometry

Online Appointment Request

To make an appointment, please call (408) 247-5102 or fill out the form below to send a request for an appointment time.

Patient Name:
Birthdate:	Month Day Year
Cell #:
Email:

Are you a new patient? Yes No

Please indicate what time you would like to schedule your eye exam. We will do our best to accommodate your request with the doctor you prefer at the time you request.

When:
Time:
Special Request:

If you want us to check your insurance before scheduling an appointment, please provide us additional information below.

Primary

Member Name:
DOB:
Member Social Security #:

Type of Vision Insurance:
Other/Specify:

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