Appointment Request Form If this is an emergency, do not contact us via email, please use our emergency contact information. Complete the following form: Please fill in the form below to setup an appointment.DoctorNo PreferenceDr. Rob. H. WagnerDr. Loree WagnerReason for AppointmentPlease provide the main reason for your appointment. Details are stored securely. -Annual Eye Exam (glasses and contacts) -Routing Medical Exam (diabetes, glaucoma, etc) -Medical Concern (pain, redness, infection, foreign object)Preferred Date & Times*Our Hours: Mondays-closed, Tuesdays- 10am-7pm, Wednesdays- 8:30am-5:30pm, Thursdays- 8:30am-5:30pm, Fridays- 8:30am-5:30pm, Saturdays- 8am-1pm, Sundays-closed. Patient Type*New patientReturning patientInsurance*Please include the name of your Vision Insurance and have your member ID information ready. We will need to verify that your plan is accepted at our office. Examples: VSP (Vision Service Plan) EyeMed (plan specific) Spectera *Or you may have vision coverage under your medical insurance. Name* First Last Phone*Email* Best Time to be Reached for Confirmation* : HH MM AM PM CommentsEmailThis field is for validation purposes and should be left unchanged.