Appointment Request – Summer Vision Clinic

KVFL will be hosting FREE Summer Vision Clinics on Friday August 15 and Saturday August 16 from 9am-2pm at our office in Maryland Heights. If you would like to request an appointment for your child, please fill out the form below.

• NOTE – This is a request form ONLY – You do not have an appointment until you receive a follow-up confirmation from KVFL staff.
• If you have multiple children in need of vision exams, please submit a request for each child.
• Appointments are scheduled on a first come, first served basis and tend to book quickly. 
• Please allow our staff up to 2-3 days to respond to your appointment request.
• If your child has lost/broken glasses but was seen by an eye doctor in the past 12 months, please stop and fill out the replacement glasses request form instead. They do not need an updated exam unless their prescription has expired.
• No walk-ins are allowed. Thank you!

PATIENT DETAILS

Patient Name *

First

Last

Patient Date of Birth *

Gender *MaleFemaleUnspecified

Current or Previous School Attended *

Previous Grade Completed *

Does your child currently wear glasses? *NoYes

If Yes – Please make sure to bring your child’s previous glasses to their appointment.

Did your child receive a vision exam and glasses from KVFL in the past 12 months? *NoYes

Did they break or lose their glasses? *NoYes

If your child was provided glasses by KVFL at their school this year and needs a replacement, you do not need to sign up for a vision exam. Please click on the “Replacement Glasses” tab at the top of the page and fill out that form to request a free replacement.

PARENT CONTACT INFORMATION

Parent Name *

First

Last

Parent Email *

please they PARENT

Parent Phone Number *

FINAL STEPS – APPOINTMENT OPTIONS

We will do our best to accommodate your preference based on availability. Exams can take up to 30 minutes per child. Please plan accordingly.

Preferred Date for your Child's Vision Exam: *

• Friday, August 15
• Saturday, August 16
• Either Date, I’m Flexible!

Preferred Time of Day for Appointment: *

• Morning (9am – 11am)
• Mid-Day (11am – 12:30pm)
• Afternoon (12:30pm – 2:00pm)
• First Available

How Did You Hear About Us?

• School Nurse
• Friend Referral
• Social Media
• Internet/Search Engine
• Other

If other, please specify

Additional Questions or Comments

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