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Enter to Win Free Custom Lasik Procedure and 1 year follow up care with a Whitten-Perraut
Laser Eye doctor.
To request an appointment, please enter the information and press the "Send Appointment Request" button when you are through. If you prefer to make and appointment by phone, please call 1-800-626-LASER (5273).
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*Patient
Name
(First, Middle, Last): |
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Date
of Birth
(mm/dd/yy): |
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| *Email
Address: |
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| Street
Address: |
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| City:
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| State:
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| Zip:
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| Country:
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| *Primary
Phone: |
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| Alternate
Phone: |
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| Best
time to call: |
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| Preferred
week day for appointment: |
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Reason for appointment:
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Do
you have:
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Whitten
Laser Eye Associates location where you would prefer your appointment:
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Enter
any general comments in the space below:
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Your name and phone number are required fields so that we can
contact you to confirm your request.
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©1999-2001 Whitten-Perraut Laser Eye Associates, All Rights Reserved
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