Appointment Request

Use this form to request an appointment with Dr. Goff. This form should not be used for urgent eye health needs or for medical emergencies. We will contact you within 24 hours to schedule your appointment. If you need immediate assistance please call our office.

Patient's Name*
First Last
Date of Birth*
MM
DD
YYYY
Phone*
Email*
Enter Email Confirm Email
How should we contact you about your appointment request?*
When is the best time to contact you about your appointment request?*
What time of day would you like an appointment?*
What day of the week would you like an appointment?*
Details
Name
This field is for validation purposes and should be left unchanged.

Call for more information!

269.244.3350

Appointment Request

Appointment Request