Appointment Request Form Please fill in the form below to setup an appointment.Reason for AppointmentPlease 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 patientReturning patientPlease let us know if you are a new or existing patient.Name* First Last Phone*Date of Birth*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year2022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Email* Best Time to be Reached for Confirmation* : HH MM AM PM I currently wear...* Glasses Contact Lenses None of the above CommentsInsurance Benefits Vision CoverageChoose Insurance Provider:BPA - Benefit Plan AdministratorsBlue Cross (Ontario)Canada LifeCanadian Construction Workers UnionChamber of Commerce Group InsuranceCINUPClaimSecureCowanDesjardins (Reimbursement only)Empire LifeFirst CanadianGMS Carrier 49GMS Carrier 50Green ShieldGroupHealthGroupSourceIndustrial AllianceJohnson Inc.Johnston Group Inc.League BenefitsLiUNA Local 183LiUNA Local 506ManionManulife FinancialMaximum BenefitSSQ InsuranceSunLife FinancialTELUS AdjudiCareI would like my eye exam and/or glasses, sunglasses or contact lenses to be billed directly to one of these Insurance providers.EmailThis field is for validation purposes and should be left unchanged.