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Appointment Request Form

Subject:  
  New patient   Existing patient
Referred by:  
Title:  
* Full Name:  
* Telephone:  
Other Telephone Number :
* Email:  
* Date of birth:
* Care Card Number:
(for identification)  
Status Number:
3rd party coverage through:
Appointment request:      
Location:  
Optometrist:  
Preferred time:     (view office hours)
Message/comments:

    
 

DUNCAN
101-394 Duncan Street,
Duncan, BC
Tel: 250.746.4634

MILL BAY
105-2690 Mill Bay Road,
Mill Bay, BC
Tel: 250.743.3411