Appointment Request Form

Please fill in the form below to setup an appointment.
THIS FORM IS NOT TO BE USED TO REQUEST AN EYE EMERGENCY APPOINTMENT - Please call our office instead for any urgent request

Name*

First Last

Age*

Patient Type*

New patient
Returning patient

Please let us know if you are a new or existing patient.

Phone*

Email*

Preferred Method of Contact*

Phone
Email

Doctor

Preferred Date & Times*

Please let us know when you would prefer to have your appointment. Our hours are listed on our location page.

Would you like to request any additional appointments for other family members?*

Yes
No

Enter Names and Ages

Comments/Reason for Examination Request*

Please provide a reason for your appointment. Details are stored securely and not sent by email.

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Phone

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

Guelph
Eye Care

Guelph Eye Care

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Appointment Request Form

Guelph Eye Care

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