Schedule a Phone Consultation

Are you a new patient and just have a couple of questions about your treatment plan?

Are you considering Vision Therapy but you just need a little more information?
Complete the form below to schedule a complimentary phone consultation.

Phone Consultation Request

To request a free phone consultation, please complete the form below. Please don't forget to include accurate contact details so we can follow up with you to finalize your request. You may also call us directly at 860-632-UC4D (8243).
Reason for Consultation Request*
Patient Type*
- New Patient
- Existing Patient
If you are a new patient and were referred to us, please indicate who referred you:*
Full Name*
First Last
Patient's Name (who is this appt. for?)*
First Last
Phone*
E-mail*
What days work best for you?*
What time works best for you?*
- Morning
- Afternoon
- Evening
Best Time to Reach You to Set Appointment*

: Hours

Minutes

AM/PM
Comments*

Thank You!