Appointment Request Form

Name: VisualEyes of the Palm Beaches: Debra A. Shim, OD, PA
Address: 451 University Boulevard, 102, Jupiter, FL, 33458, US
Telephone: 561-625-4380

Please fill in the form below to setup an appointment.
Reason for Appointment
Please provide a reason for your appointment. Details are stored securely and not sent by email.
Preferred Date & Times*
Please let us know when you would prefer to have your appointment. Our hours are listed on our location page.
Patient Type*
- New patient
- Returning patient
Please let us know if you are a new or existing patient.
Name*
First Last
Phone*
Consent
By checking this box, I consent to receive SMS text messages from VisualEyes of the Palm Beaches for appointment reminders, marketing messages, and general two-way communication. Msg frequency varies. Msg&data rates may apply. Reply HELP for support. Reply STOP to opt out.
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Email*
Best Time to be Reached for Confirmation*

: Hours

Minutes

AM/PM
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