Samantha Slotnick, OD, FAAO, FCOVD
495 Central Park Ave, Suite 301, Scarsdale, NY 10583
Contact us at (914) 874-1177 or jane@drslotnick.com
Email address
Name
Your answer
Phone
Your answer
Please add me to your Newsletter (~4/year):
I am interested in...
Required
Preferred contact... (check any acceptable)
Required
I am concerned about...(check all that apply)
I am (check all that apply)
I have / my child has... (check all that apply)
Specific concerns include... (check all that apply)
Please email me the visual symptoms self-quiz!
A copy of your responses will be emailed to the address you provided.
Please complete the captcha before submitting the form.
Submit
Never submit passwords through Google Forms.
This form was created inside of Samantha Slotnick, OD, FAAO, FCOVD. Report Abuse - Terms of Service - Additional Terms