Make an appointment: (519) 426-3123
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Services
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Our team
Vision info
Contact us
Appointment Form
Appointment Form
SOI 6860
2015-04-06T15:13:44+00:00
First Name
*
Last Name
*
Email
*
Phone number
*
(###) ### ####
Are you a contact lens wearer?
*
Yes
No
Preferred Doctor
Dr. Michael Zona
Dr. Linda Hadaller
Dr. Amber McKnight
Dr. Allison VanBerlo
Dr. Matthew Czikk
no preference
Can we phone you to book this appointment?
Yes, please.
No, thank you, I prefer email.
Preferred Day - check any that apply
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday - June 2020 or Sept 2020
No preference
Preferred Time
*
7:45AM-10AM
10AM-12PM
12PM-2PM
2PM-4:30PM
Will you be looking for new glasses at this appointment?
*
Yes
No
If you want to choose new glasses, the same day as your exam, please let us know, now - as we need to book an appointment with our Optical Staff the same time as we book your exam with your doctor. Thank you.
Referred by
Message / Comments
*
I am a
*
Existing Patient
New Patient
If you are a NEW PATIENT, please complete the additional field below, thank you.
Address
*
Please include full mailing address, including PO Box numbers and postal code.
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Email
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Contact Info
100 Colborne Street N
Simcoe, ON N3Y 3V1
Phone:
519-426-3123
Fax: 519-426-8594
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