Contact Form

For Appointments, Free Booklets or a Free LASIK Screening

If you are interested in obtaining more information on a specific topic, setting up a free LASIK screening, or scheduling a comprehensive eye exam, please utilize the following form or call out Communications & Education Department at 414-321-7035.  Our office will contact you promptly to handle your questions and requests.

 

First Name:
Last Name:
Street Address:
City:
State / Zip:
Home Number:
Work Number:
E-mail:
How did you hear about our website?

 

Which educational materials would you like to receive?
(Booklets are hard copies of the same information that appears on this website.)
Laser Vision Correction Booklet
Laser Vision Correction Video
Cataract Surgery Booklet
Diabetic Retinopathy Booklet
Dry Eye Syndrome Booklet
Glaucoma Booklet
Macular Degeneration Booklet
Would you like someone to contact you by telephone to discuss a particular concern?
What topic?

    

E-mail Us...

If you have any questions or concerns that are not directly addressed in our Contact Form, 
please e-mail us at:

ECS321eyes@aol.com

 

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