Appointment Request Form 1Appointment Request2Patient Information3Confirmation Name* First Last Appointment TypeGeneral Eye CareVision Therapy/Developmental Optometry/Neuro-Optometric RehabilitationScleral Lenses Assessment/Fitting/FollowupDry Eye Assessment/Treatment/FollowupMyopia Control Assessment/Fitting/Follow-UpIf unsure, select Vision TherapyReason?*Appointment Type*General Eye CareVision TherapyMyopia ControlScleral LensesPreferred Date/Time* New or Returning?* New patient Returning patient Provincial Health Card Number (including the two letter version code if applicable)*Date of Birth MM slash DD slash YYYY Do you wear contacts? Yes No Confirm by* Phone Email Phone*Best Time to be Reached for Confirmation* Hours : Minutes AM PM AM/PM Email* CommentsThis field is for validation purposes and should be left unchanged. Δ