Appointment Request Form

Name: Saugeen Shores Family Eye Care
Address: 643 Devonshire Road, Port Elgin, ON, N0H 2C3, CA
Telephone: (519) 832-5511
Price range: $000 - $300

**If you’re experiencing anything more urgent than a routine appointment, please call our office instead of filling out this form**

Basic form for clients to request an appointment with the practice.

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.
Patient Type*
- New patient
- Returning patient
Please let us know if you are a new or existing patient.
If you are a new patient, please fill out the following intake form:
Name*
First Last
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Date of Birth*
MM slash DD slash YYYY
Best Time to be Reached for Confirmation*

: Hours

Minutes

AM/PM
Phone*
Please provide a telephone number, with area code, so we can contact you.
At this time, we are following up with all appointment requests by phone only as there's a lot more to discuss with COVID protocols than before.
Preferred day of the week for your appointment (select all that apply):*
- Monday
- Tuesday
- Wednesday
- Thursday
- Friday
Preferred time of day for your appointment*
Comments
Phone
This field is for validation purposes and should be left unchanged.