Appointment Request Form Name* Date of Birth* Please fill in the form below to setup an appointment.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 : If you are a new patient please fill out New Patient Form* Returning patient New Patient: If you are a new patient, please fill out our Patient Registration form under "Our eye Care Clinic" Are you covered under any Ontario funding?* Ontario Works Indigenous Status ODSP (Ontario Disability Support Program) None Other Birth-Date* MM slash DD slash YYYY Phone*Email* Best Time to be Reached for Confirmation* : Hours Minutes AM PM AM/PM CommentsDate MM slash DD slash YYYY Untitled NameThis field is for validation purposes and should be left unchanged.
* Closed long weekends.