Ilex Eye Associates - Request an Appointment

Request an Appointment

This form is for routine care only. For emergencies during regular office hours, please call 519.885.4539; for emergencies on weekends or holidays, please call 519.590.9529

Your First Name(*)

Please state your first name

Your Last Name(*)

Please provide your last name

Your E-mail Address(*)

Please provide an e-mail address to send a reply/confirmation of this request to.

Daytime Phone Number(*)

Please provide a daytime phone number that we can contact you with...

Preferred Doctor

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----------- Select your preferred appointment day -----------

Choose your preferred day by clicking the date on the calendar (Mon-Friday only)(*)

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Your preferred time(*)

Please choose a day you would like your appointment

----------- Select an alternative appointment day -----------

Choose an alternative day in case your preferred one is unavailable (Mon-Friday only)

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Your alternative appointment time

Please choose a day you would like your appointment

Comments or requests

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Request an Appointment

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