Call (613) 507-0707

745 Gardiners Rd. Unit 3

Kingston, ON K7M 3Y5

Open Hours

Mon - Thu: 8:30am - 5:00pm

Fri: 8:30am - 4:00pm

Appointment Request Form - New Patients

This form is for new patients wanting a comprehensive eye exam. If you require any other appointment type, aside from a full comprehensive exam, please call our office.

If you do not require an eye appointment and ONLY require an appointment with one of our Opticians for a repair, pick-up, or adjustment, please use our Contact Us form, and one of our opticians will contact you directly.

Please refer to our Pricing Policy if you have any questions about our fees. Our online forms are secure and PIPEDA compliant.

Patient Information Please select an item. Please enter your Health Card Number and Version Code. Please enter your full name, as it appears on your Health Card. Please enter your Date of BirthInvalid format. Please enter your family physician. Please enter your phone number. Please select an item. Please enter your full address.
Please select a Driver's License Class. Please select an item.
Vision Insurance Please select an item. By completing the information below, I certify that I agree to the
Vision Insurance Consent - Terms and Conditions

Patient Allergies Please select an item. Please select an item.
Patient Medical Conditions

Patient Medications Please select an item.
Family Ocular History

Referrals Please select an item.
Eyewear Please select an item.

Comprehensive Eye Exam Request

If you prefer to see a specific doctor, please make sure to check the doctor's schedule before requesting a time. Click Here to View Doctors' Schedule
Please select an item. Please select an item. Please select an item. A value is required. Please select an item.



COVID-19 Screening Precautions

I certify that I will not come to my appointment if any of the following apply:
1. I have cold or flu like symptoms (such as fever, cough, shortness of breath, sore throat, runny nose, sneezing, difficulty swallowing, nausea, chills, headache).
2. I have travelled outside Ontario or have had close contact with anyone that has travelled outside Ontario within 14 days of my appointment.
3. I have had close contact with anyone with respiratory illness or a confirmed or probable case of COVID-19 within 14 days of my appointment.

You must certify that you agree to COVID Screening Precautions.
All questions marked with an * must be completed for the submit button to work.