Appointment Request Form

Vision Insurance/ Insurance (if any):
Insurance Number:
I would like an appointment with:

Please select up to 3 appointment dates / times.
If you can't find a convenient appointment time, please call our office

Enter Letters Shown

Please Note: The requested appointment time(s) may no longer be available. We will contact you to confirm your actual appointment date and time.

Practice Photo
  • Jorgensen, Schulz and Associates EyeCare Center

    Bradley Jorgensen, O.D.
    Robert Schulz, O.D.
    Francie Laeyendecker, O.D.
    Jacob Wittman, O.D.

    1225 W Northland Avenue
    Appleton, WI 54914