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
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  • W. SAM SHIELDS, O.D. & ASSOCIATES

    W. Sam Shields, O.D.
    James Yi, O.D.
    Lisa Maier,O.D.

    2812 Cochran St.
    Simi Valley, CA 93065

    805-527-6164