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

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)