Book an Appointment

Please complete the form below to request an appointment at Burlington Eyecare. We will gladly confirm your appointment by phone or e-mail within one business day. For immediate assistance in booking your appointment, please phone our office at 905-639-9595.

Patient Information

Name: *

Address: *

Home Phone #: *

Cell #:

Date of Birth: *

Health Card #: *

Health Card Version Code:

New or Returning Patient: *

New Patient

Returning Patient

Email Address: *

Appointment Preference

Month: *

Year: *

Day of the month:

Day of the week: *

Time Preference: *

Question or Comments Regarding this Appointment: