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 519.651.2872Name* 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*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Phone*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 EmailThis field is for validation purposes and should be left unchanged.
