Request an Eye Exam

Please fill out the form below completely to request an Eye Exam with Optical Outlets. Patients need to complete this form. You will receive a call from a representative to complete your requested appointment. Thank you.

You can also call us for more info at 1-800-849-3937

Full Name*
Email *

Phone Number*
Type of Insurance/Name of Plan
If none, please leave blank.
Eye Exam Type
Eyeglasses
Sunglasses
Contacts

Choose a Location (Enter your 5 digit zip code)*


Requested Appointment Date
Requested Appointment Time
Reason for visit. (If this is an emergency call 9-1-1)

$(document).ready(function() { $(window).keydown(function(event){ if(event.keyCode == 13) { event.preventDefault(); return false; } }); });