Appointment Request Form

Name*
Date of Birth*
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 : 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
Comments
Date
MM slash DD slash YYYY
Untitled
Name
This field is for validation purposes and should be left unchanged.

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