Appointment Request Form Please fill in the form below to setup an appointment.Name* First Last Have been to our office for an exam previously?* Yes No Date of Birth*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year2022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Phone*Email* Do you have any of the following conditions: diabetes (medicated or diet controlled), glaucoma, eye turn, lazy eye, or cataract?* YES NO Unfortunately we cannot book an appointment for you at the moment. Currently, all Ontario optometrists are in a job action due to a breakdown in negotiations with the government, and have made the difficult decision to withdraw from delivering any exams that may be OHIP eligible at this time. (Please refer to https://www.saveeyecare.ca/ for more information.) You can seek eyecare, however, from: 1. Your family physician who can either treat you, or refer to an ophthalmologist, or to the on-call ophthalmologist if an emergency. 2. A walk in clinic who can refer appropriately if needed. 3. Emergency Department who can either treat you or arrange care from the on-call ophthalmologist. 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.