First Name*

Last Name*

Phone Number*

Email Address*

New PatientExisting Patient

Preferred Day of the Week:
MondayTuesdayWednesdayThursdayFridaySaturdaySunday

Preferred Time:
MorningsAfternoonEvenings

Reason for Appointment:
Eye ExamOptical/Glasses InquiryOther

Preferred Location:
Downtown (340 Spadina Ave.)North York-Uptown (Yonge & Finch) (5357 Yonge St.)North York-Downsview (1619 Wilson Ave.)