Eye Exam Request Form

Please note this is a request only. Our team will be in touch to schedule and finalize your exam time as soon as possible — we are proud of our quick response!

Alternatively, you may call your preferred location to schedule your appointment directly.

Patient Name(required)

Address(required)

Daytime Phone(required)

Email Address(required)

Which office would you prefer to schedule an exam?(required)

When would you prefer your appointment?(required)

What time of day works best for you?(required)

Purpose of Visit(required)

Please use this space for any special requests or concerns

This field should be left blank

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At Kennedy & Perkins we care about you and the health of your eyes, and look forward to providing you the highest quality vision care at each and every appointment. In order to provide this level of care for all of our patients we have created a Patient Attendance policy. This is posted in our office, on our website, and will be emailed with all appointment confirmations.

When you schedule an appointment with our office we prepare your records, verify and research insurance coverage(if applicable), and reserve the doctor’s time to provide you the care you deserve. We understand that changes in your schedule may occur , and we ask that you contact our office as soon as possible if you need to reschedule. This allows us to release your reserved appointment to another patient who needs care. If you are unable to provide at least 24 hours notice, or you do not come in for your scheduled appointment, this will be considered a “no show” and the policies outlined below will apply.

1st no show: We understand the situations such as personal or medical emergencies arise, no fee is applicable.
2nd no show: We understand the situations such as personal or medical emergencies arise, no fee is applicable. However, if you wish to reserve an appointment for a 3rd time, a $50.00 deposit is required.
3rd no show: In the event of a third missed appointment, without 24 hours prior notice, our staff will be unable to reserve future appointment times for you. In this circumstance, please contact K&P management for further options.
4th no show: In the event of a fourth missed appointment without prior notice, our staff will be unable to reserve future appointment times for you, in this case, please contact K&P management with any further concerns.