Appointment Request Form

Name: Our Office
Address: 1209 King Street West, Unit 3, Toronto, ON, M6K 1G2, CA
Telephone: 416-588-8688
Price range: $000 - $300

Please fill in the form below to setup an appointment.
Reason for Appointment
Please provide a reason for your appointment. Details are stored securely and not sent by email.
Preferred Date & Times*
Please let us know when you would prefer to have your appointment. Our hours are listed on our location page.
Patient Type*
- New patient
- Returning patient
Please let us know if you are a new or existing patient.
Name*
First Last
Phone*
Date of Birth*
Email*
Best Time to be Reached for Confirmation*

: HH

MM
I currently wear...*
- Glasses
- Contact Lenses
- None of the above
Comments
Insurance Benefits Vision Coverage
I would like my eye exam and/or glasses, sunglasses or contact lenses to be billed directly to one of these Insurance providers.
Comments
This field is for validation purposes and should be left unchanged.

Our Office