Request an Appointment

Appointment Request Form

* Indicates required field

Name *

First

Last

Email *

Date of Birth (mm/dd/yyyy) *

Gender *

Male Female

Patient Status *

New Returning

Cell Number *

Home Number *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Vision Insurance (if applicable) *

Insurance Number (if applicable) *

Doctor Preference *

Location *

Dr. Kahrhoff's availability:
M Festus
T Festus
W Webster Groves
Th Webster Groves
F Festus
S Webster Groves/Festus

Dr. Derek Wiles' availability:
M Leadington
T Leadington
W Festus
Th Leadington
F Leadington
S Leadington/Festus

Dr. Brenon's availability:
M Leadington
T
W Leadington
Th Leadington
F
S Leadington

Dr. Williams' availability:
M
T Leadington
W
Th
F
S

Dr. Crane's availability:
M Webster Groves
T Webster Groves
W
Th Festus
F Webster Groves
S Webster Groves

Dr. Radakovic's availability:
M
T
W Webster Groves
Th
F
S Webster Groves

Dr. Jarka's availability:
M Webster Groves
T
W
Th
F
S

Office Hours of Operation:
Leadington M 8:30-6:00, T-F 8:30-5:00, S 7:30-12:00 | Festus M-W&F 9:00-5:00, Th 10:00-6:00, S 7:30-12:00 (1st/3rd Sat only) | Webster Groves M,T,Th 9:00-6:00, W,F 9:00-5:00, S 9:00-1:00

Please select 3 appointment dates and times:

**When selecting appointment times and dates, please attend to doctor availability at desired location and times.

1st Preference Date (mm/dd/yy) *

1st Preference Time *

2nd Preference Date (mm/dd/yy) *

2nd Preference Time *

3rd Preference Date (mm/dd/yy) *

3rd Preference Time *

Please enter purpose of appointment / comments. *

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

Submit

Appointment Request Form

Complete Vision Care, Inc | Career Opportunities﻿

Complete Vision Care, Inc | Career Opportunities