Appointment Request Form Please fill in the form below to setup an appointment.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, Lazy Eye (amblyopia), Eye Turn (strabismus)* Yes No Date of Birth*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Phone*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:* 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.
