Appointment Request Form Basic form for clients to request an appointment with the practice. Please fill in the form below to setup an appointment.DoctorSelect>>No PreferenceDr. Barry M. Gaffney, O.D. P.A.Dr. Jeremy H. Gaffney, O.D.Dr. Daniel G. Gaffney, O.D.Reason for AppointmentPlease 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 patientReturning patientPlease let us know if you are a new or existing patient.Name* First Last Phone*Email* Best Time to be Reached for Confirmation* : HH MM AM PM CommentsPhoneThis field is for validation purposes and should be left unchanged.