Appointment Request Form Please fill in the form below to setup an appointment.This field is hidden when viewing the formReason for AppointmentPlease provide a reason for your appointment. Details are stored securely and not sent by email.Patient Type* New patient Returning patient Please let us know if you are a new or existing patient.This exam is for:* A child An adult Our practice specializes in Myopia Management for children. Nearsightedness / myopia is one of the leading causes of eye disease in adults, but myopia management can slow down myopic progression in your child and help prevent glaucoma, macular degeneration, etc. If you haven't heard about myopia management, please click here here to learn more about it. If it is relevant for your child, our eye doctor will introduce you to myopia management at the eye exam. Feel free to contact us at 587-603-5840 before your child's eye exam to learn more about this service or browse our website for further information. Reason for Appointment* Child is getting more nearsighted each year. Learn More Here Myopia Management or Control Ortho-K or CRT or GVSS (Vision Correction) Regular Eye Exam Contact Lens Exam Other Choose from any of the following options. Reason for Appointment* High Astigmatism or High Prescription Keratoconus or Irregular Cornea Safe alternative to LASIK w/o surgery Ortho-K (Vision Correction) Eye Conditions and Diseases Regular Eye Exam Contact Lens Exam Other Please Specify*Please Specify*During your exam, would you be interested in hearing about controlling nearsightedness progression?* Yes Not at this time Preferred Date & Times*Please let us know when you would prefer to have your appointment. Our hours are listed on our location page.Name* First Last Phone*Email* How did you find us?*Friend/FamilyGoogle Search/WebsiteSocial MediaDoctor ReferralOtherPlease Specify*Please Specify*This field is hidden when viewing the formBest Time to be Reached for Confirmation* : Hours Minutes AM PM AM/PM CommentsCAPTCHANameThis field is for validation purposes and should be left unchanged. Δ
