Appointment Form

Title

First Name*

Last Name*

Phone Number*

(### - ### - ####)

Email*

Date of birth*

Are you a contact lens wearer?*

Preferred Doctor

Preferred day*

Hour*

Referred by

Message / Comments

I am a*

If you are a NEW PATIENT, the 2 additional fields below must be completed, thank you.

Address*

Please include full mailing address, including PO Box numbers and postal code.

Health Card #*

Please include the *** full 10 digit number, *** the 2 letter version code and *** the expiry date.

Name

This field is for validation purposes and should be left unchanged.