Appointment Request
You can text us at 416-703-2797 if you you prefer.
Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Date of Birth
*
-
Month
-
Day
Year
Date
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Current or New Patient
*
Current Patient
New Patient
Preferred Doctor
*
Please Select
First Available Appointment
Dr. Hazra
Dr. Wilkinson
Dr. Heeney
Preferred Appointment Day
*
Please Select
First Available
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Preferred Appointment Time
*
Morning (9:00-10:30)
Late Morning (10:30-12:00)
Early Afternoon (12:00-3:00)
Late Afternoon (3:00-5:00)
Reason for Appointment
*
This is an emergency
Eye Exam
Glasses
Contact Lenses
Other
Additional details
Please verify that you are human
*
Send Request
Should be Empty: