Request an Appointment Online

Please fill out the following form if you would like to request an appointment online. We will contact you to confirm your appointment via your preferred contact method. If you are interested in an appointment within the next 24 hours, please call (816) 524-8900.

Appointment Request Form

* Required Field

* Person Requesting Appointment:
* Patient First Name:
* Patient Last Name:
* Patient Date of Birth:
* Type of Appointment Please select Childrens Exam Adult Exam Allergy Lasik Evaluation Other

* Which Doctor would you like to see?

Dr. Julie Anderson	Dr. Miriam Anderson	Dr. Kari Burchett	Dr. Doug Herriott	Dr. Mark Herriott
First Available No Preference

* What would be the best way to contact you?

Phone Email
* Best Contact Phone:
* Contact E-mail:

1st Choice

* First Preference Appointment Date:
* First Preference Appointment Time Please select AM PM After 3 PM

2nd Choice

* Second Preference Appointment Date:
* Second Preference Appointment Time Please select AM PM After 3 PM

Other Comments