Name *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Phone *

(###)

###

####

Are you an existing patient of our clinic? *

Yes

No

Do you wear contact lenses? *

Yes

No

No, but I am interested in contact lenses

Reason for appointment *

Eye examination

I have noticed a change in my vision

I need new glasses or contact lenses

I am experiencing, red, dry or irritated eyes

Other (please specify in comment field below)

Which doctor would you like to be booked with? *

Dr. Carmen Dumalo

Dr. Jessica Melville

Dr. Kimberly Kishi

No preference

As part of your visit, would you like to book a complimentary consultation to discuss glasses options with one of our opticians?

Yes

No

Preferred appointment day *

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

No preference

Preferred appointment time *

Early morning

Late morning

Early afternoon

Late afternoon

Evening

No preference