Appointment Request Form

Monday: 9:00 AM - 5:00 PM
Tuesday: 9:00 AM - 5:00 PM
Wednesday: 9:00 AM - 5:00 PM
Thursday: 9:00 AM - 7:00 PM
Friday: 9:00 AM - 5:00 PM
Saturday: 9:00 AM - 1:00 PM
Sunday: Closed

To request your next appointment, please complete the form below and we will contact you with our first available appointment time. Please don’t forget to include accurate contact information so we can follow up with you to finalize your request. Thank you!

**ALL INFORMATION IS REQUIRED**

Please fill in the form below to setup an appointment.
Doctor
Patient Type*
- New patient
- Returning patient
Please let us know if you are a new or existing patient.
Name*
First Last
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Home Phone*
Cell Phone*
Date of Birth*
Year/Month/Day
Health Card Number*
Email*
Previous Diagnosed Eye Conditions*
Serious Medical Conditions*
Reason for Appointment
Please provide a reason for your appointment. Details are stored securely and not sent by email.
Comments
Phone
This field is for validation purposes and should be left unchanged.

Appointment Request Form

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