Appointment Request Form Please fill in the form below to request an appointment for routine care. DO NOT USE THIS FORM FOR URGENT MATTERS AS IT MAY NOT BE SEEN IN A TIMELY MANNER. PLEASE CALL THE OFFICE 519.651.2872Salutation* Mr. Mrs. Miss Ms. Name* First Last Have you been to our office for an exam previously?* Yes No Do you have any of the following conditions: Glaucoma, Diabetes ?* Yes No Date of Birth*MonthMonth123456789101112DayDay12345678910111213141516171819202122232425262728293031YearYear20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Phone*Email* Address* Street Address Address Line 2 City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code Reason for Appointment*Please provide a reason for your appointment. Details are stored securely and not sent by email. Please note this is not for emergencies or urgent issues.Do you have insurance?* Yes No Insurance Provider:*We can direct bill most insurance companies. Depending on the details of each individual plan/policy there may be instances, however, when this cannot be done. In these cases, you would have to pay for any services and/or products provided and submit the claim yourself. Acknowlegement:* I understand that I may have to submit my own insurance claim.*Preferred Day of the week / Time of day* Contact me by:* phone e-mail PhoneThis field is for validation purposes and should be left unchanged. Δ
