Appointment Request Form

Use this form to request an appointment with us. While we will do our best to accommodate your requested day and time, please note, your appointment is not fully booked until you get a confirmation from us.

We will call within 48 hours to confirm day and time of appointment. If you do not hear from us within that time, then please call (763) 553-1811 to confirm appointment.
Name*
First Last
Date of Birth*
Month
Day
Year
Email*
Select Date
MM slash DD slash YYYY
Phone*
Select Time
Notes to the Doctor
Please do not submit any Protected Health Information (PHI).
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Bass Lake Family Eye Care