Request an Eye ExamPatient Name*AddressZip Code*Phone*Email* Which location would you prefer to schedule an exam?Alexandria, MNBismarck, NDDetroit Lakes, MNFargo, NDFergus Falls, MNHutchinson, MNLittle Falls, MNMarshall, MNMinot, NDMontevideo, MNMoorhead, MNMorris, MNSt. Cloud, MNThief River Falls, MNVirginia, MNWadena, MNWahpeton, NDWilmar, MNWhat day do you prefer your appointment?* Monday Tuesday Wednesday Thursday Friday Saturday SundayWhat time of day works best for you?* Morning Midday AfternoonPurpose of Visit* Annual Exam Eyeglasses Contacts Prescription Sunglasses OtherSpecifyPlease use this space for any special requests of concerns
