Request an Appointment

Fill out the form below to schedule an appointment with Optic Gallery Summerlin.

Appointment Request Form

You can request an appointment directly with Optic Gallery Summerlin by filling out this form. Once we receive the form, we will contact you to finalize your appointment date and time. To schedule an emergency appointment, or to check the availability of same day appointments, please call our office at: 702-654-2020.

Name(Required)

First Last

Email(Required)

Enter Email Confirm Email

Phone(Required)

(xxx) xxx-xxxx

Patient Status(Required)

Please indicate if you are a new patient or an existing patient.

New Patient

Existing Patient

Preferred Appointment Date(Required)

Please indicate the Day and time you prefer for your appointment.

Preferred Day of Appointment(Required)

Choose the day or days that you prefer for your appointment.

Preferred Appointment Time(Required)

Please indicate the best time(s) you would prefer for your appointment.

Morning

Afternoon

No Preference

Preferred Optometrist(Required)

First Available

Dr. Jordan

Dr. Radtke

Dr. Saldivar

Insurance Provider(Required)

Please indicate your insurance provider.

Comments(Required)

Please let us know the nature of your visit (Glasses and/or contact lens exam, red eye, floaters, etc.) and any other details we may need regarding your appointment.

This field is for validation purposes and should be left unchanged.