Biondolillo Appointment Request Date of Conversation(Required) MM slash DD slash YYYY Patient Name(Required) First Last Date of Birth(Required) MM slash DD slash YYYY Preferred Doctor(Required)Preferred DoctorDr. GardnerDr. BeiterPatient Phone Number(Required)Preferred Time to Call Back Hours : Minutes AM PM AM/PM Preferred time / date for appointmentTime Hours : Minutes AM PM AM/PM Date MM slash DD slash YYYY Notes from conversationNames of Other Patients to Schedule Appointments: By providing my phone number to “Your Local Eye Doctor”, I agree and acknowledge that “Your Local Eye Doctor” may send text messages to my wireless phone number for any purpose. Message and data rates may apply. Message frequency will vary, and you will be able to Opt-out by replying “STOP”. For more information on how your data will be handled please visit or see the privacy policy below. Privacy Policy: No mobile information will be shared with third parties/affiliates for marketing/promotional purposes. All the above categories exclude text messaging originator opt-in data and consent; this information will not be shared with any third parties.