Request an Appointment - Ophthalmic Associates

To request an appointment please use the below form. Please allow 24 to 48 hours for a response.

Please call for URGENT requests. This form is only for general requests and will not be seen for 24 hours.

Name*
First Last
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Date of Birth
Phone*
Email*
Date Requested (Preferred)*
Date Format: MM slash DD slash YYYY
Date Requested (Alternate 1)
Date Format: MM slash DD slash YYYY
Date Requested (Alternate 2)
Date Format: MM slash DD slash YYYY
Date Requested (Alternate 3)
Date Format: MM slash DD slash YYYY
Who do you prefer to see*
Reason for visit*
Office Requested
- Downtown Johnstown
- Richland
- Windber
- Meyersdale
- Northern Cambria
- Somerset/Georgian Place
- Vinco
What Kind of Insurance Do You Have (if any)?