Appointment Request Form

Name: Stouffville Optometry
Address: 6085 Main Street, Stouffville, ON, L4A 3R4, CA
Telephone: (905) 642-3937
Price range: $000 - $300

To request your next appointment, please complete the form below and let us know the most convenient time and date for you. Please don’t forget to include accurate contact details so we can follow up with you to finalize your request.

Please add the best phone number to reach you and include in the comment field, the best method to contact you, phone, email or text (please include cell number)

Please fill in the form below to setup an appointment.
Doctor
Reason for Appointment
Please provide a reason for your appointment. Details are stored securely and not sent by email.
Preferred Date & Times*
Please let us know when you would prefer to have your appointment. Our hours are listed on our location page.
Patient Type*
- New patient
- Returning patient
Please let us know if you are a new or existing patient.
Name*
First Last
Phone*
Email*
Best Time to be Reached for Confirmation*

: HH

MM
Comments
Phone
This field is for validation purposes and should be left unchanged.

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