Appointment Request Form

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*

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

How did you hear about our office?

Name*

First Last

Date Of Birth*

DD/MM/YYYY

Address*

Street Address Address Line 2 City Province Postal Code

Home Phone

Cell Phone

Email*

Comments

Name

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

Waterloo Vision Care Clinic