Appointment Request Form

Monday: 8:30 AM - 4:30 PM
Tuesday: 8:30 AM - 4:30 PM
Wednesday: 11:00 AM - 7:30 PM
Thursday: 11:00 AM - 6:00 PM
Friday: 9:00 AM - 1:00 PM
Saturday: Closed
Sunday: Closed

Name: Freelton Eye Care
Address: 835 Regional 97 Road, Freelton, ON, L8B 0Z4, CA
Telephone: 905-659-3937
Price range: $000 - $300

If this is an emergency, do not contact us via email, please use our emergency contact information.

Complete the following form:

Please fill in the form below to setup an appointment.
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*
Date of Birth
Date Format: MM slash DD slash YYYY
Best Time to be Reached for Confirmation*

: HH

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