Request an Appointment

At Fresh Coast Optical, we provide the highest quality service to all our patients. Use the form below to request your appointment. Please indicate your preferred date and time. Please note that we will reach out to you first to confirm your appointment or to provide you with an alternative date. You may also call us to request an appointment. Thank you!​​​​​​​

Patient Name

Patient Date of Birth

Patient Address

Type of Insurance:

​​​​​​​Name of Insurance

Policy Number