Appointment Request Form

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

Please fill in the form below to begin setting up your appointment:
Location
Doctor
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 at the bottom of the page.
Patient Type
- New patient
- Returning patient
Please let us know if you are a new or existing patient.
Name*
First Last
Phone*
Date of Birth*
MM slash DD slash YYYY
Alberta Health Care Number*
Email*
Address*
Street Address Address Line 2 City Province Postal Code
Comments
Do you wear contacts?*
- Yes
- No
Privacy & Billing Policy
Privacy Policy
Viewpoint Eye Care follows the Alberta Government’s Privacy Act. This legislation exists to protect your personal information from improper disclosure. The information we collect and disclose is used only for the treatment and management of your vision and eye health. Please refer to our Privacy Policy manual for more information regarding this practice. I agree to Viewpoint Eye Care collecting, using and disclosing personal information about me as outlined in this privacy policy. I understand that all fees charged are my responsibility, and if Alberta Health Care, or my third party insurance rejects my claims, I will pay the full amount.
Billing Policy
I understand that all fees charged are my responsibility, and if Alberta Health Care, or my third party insurance rejects or leaves my claims pending, I will pay the full amount.
Signature*
Date*
MM slash DD slash YYYY
Printed Name
First Last
Phone
This field is for validation purposes and should be left unchanged.

Appointment Request Form

Privacy & Billing Policy

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