Appointment Request - Woodstock Optometrist | Drs. Brant, Khanna & Thornton

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Please note : In case of emergency, please contact the office immediately at (519)290-3937 (during normal business hours) or go directly to your local emergency room rather than using this form.
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Please note that this form is to request an appointment only. We will contact you to confirm that we are able to offer the time-slot you have requested.
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Full Name* This field is required.Please enter your title and name
Prefix
First Name
Last Name
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E-mail* This field is required.Please provide us with your e-mail address
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Phone Number* This field is required.Please provide us with a phone number where you can be reached.
Area Code
Phone Number
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Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
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Other
Country
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Date of Birth* This field is required.
Month
Day
Year
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Preferred method of contact?* This field is required.
Email
Phone
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OHIP Number* This field is required.
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Are you currently a patient at our clinic?
YESNO
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Is your eye exam paid for by any of the following?
Ontario Works
ODSP (Ontario Disability)
OHIP
I am not sure
None of the above
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Have you been diagnosed with any or the following ?
Diabetes
Retinal Disease (Macular Degeneration)
Glaucoma
Cataracts
Strabismus (Crossed Eyes)
Amblyopia (Lazy Eye)
Visual Field Defects
Corneal Disease
Recurrent Uveitis
Optic Pathway Disease
None of the above
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Normal business hours are 8:30 AM - 5:00PM Monday to Friday. We are closed statutory holidays.
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Preferred optometrist* This field is required.If you'd like to be booked with a specific optometrist - please select dates which fall on the day of the week that are associated with the optometrist you'd like.
No preference
Please Select
No preference
Dr. Jillian Thornton (Tues AM, Wednesday, Thursday, Friday)
Dr. Sally Brant (Tuesday, Wednesday, Thurs AM Friday)
Dr. Jason Khanna (Monday, Tuesday, Thursday, Friday AM)
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Requests
1st Available
Other
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Please let us know of any concerns that you may have
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Terms and Conditions* This field is required.
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Type a question
Huge
Large
Normal
Small
Ok
Ok
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Please note that this form is to request an appointment only.

We will contact you to confirm that we are able to offer the time-slot you have requested.
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