Eye Exam Request - Klauer Optical & Sunglass Center

Name

Phone Number(required)

Email address(required)

Which location works best for your exam?

Dubuque

Cedar Rapids

What day or days work best for your exam?

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

When works best with your schedule?

Morning

Midday

Afternoon

What sort of exam are you seeking?

Annual Exam

Eyeglasses Exam

Contact Lens Exam

Follow Up Exam

Other

Do you have optical insurance?

No

Eyemed

Delta

Aetna

Avesis

MetLife

Humana

Medicare

Other

Please use this space to express any special requests or concerns we might cover during your exam