Name:

email:

Telephone #:

Address:

Have you been
with us before?:

Payment
Method:

Appointment
Request
Date:

Time:

Special
Circumstances:
NO
(xx-xx-2004)

(4:00pm -or- "morning" or "afternoon" for flexibility)
Robert D. Gillett O.D.
418 West Putnam Avenue | Porterville, California 93257 |  559.784.4063
Appointment Request
       *We will make every attempt to make an appointment as close to your request as
possible.          Appointment confirmation will be sent to your email.  There is no guarantee
to                            appointment time prior to confirmation.  Thank you for your understanding.

      ** Please make requests at least 2 weeks prior to desired appointment time and date.
First, Middle Initial, Last
YES