Request an Appointment

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When you fill in this form to request an appointment, we will contact you within the next business day to discuss your appointment request and confirm your appointment. Please indicate in the form how you prefer to be contacted.

All fields indicated with a red asterisk (*) must be filled in before the form can be sent.

Your name: *

Your complete address: *

Your email: *

Your daytime phone number: *

Your cellphone number:

How would you like us to contact you? *

☐Email

☐Daytime phone

☐Cellphone (if provided above)

Your date of birth: *

Health card number (new patients only):

Which doctor would you like to see? *

o Dr. Popick

o Dr. Caines

o No Preference

What is your preferred day? *

o  Monday

o  Tuesday

o  Wednesday

o  Thursday

o  Friday

o  No preference, would like earliest available date

What is your preferred time of day? *

o  Morning

o  Afternoon

o  No preference

What is the purpose of your visit? *

o  Routine eye examination

o  Contact lens inquiry

o  Refractive laser surgery inquiry

o  Red eye

o  Other (please indicate other reason below)

Please indicate purpose of visit if you chose Other above: