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Clinic Hours
Mon - Wed : 11am - 7pm
Thu - Sat : 10am - 7pm
Sun : 11am - 7pm
Our Office
4520 Ebenezer Road, Unit 1 Brampton, ON - L6P 2R2
Call Us
905-913-1109
Book Eye Exam
Menu
Home
Services
Dry Eye Treatment
Blepharitis
Astigmatism
Far sighted & Near sighted
Cataracts
Red Eye or Conjunctivitis
Hordeolum
Uveitis or Eye Inflammation
Contact Lenses
Diabetes
Glaucoma
Eye Injury
Laser Surgery
Ophthalmologist Consult Referral
Myopia Management
OCT Scan
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About Us
Brands
Directions
New Patient Registration Form
Routine Patient Registration Form
Eye Exam Referral Form
Eye Exam Referral Form
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Eye Exam Referral Form
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1
Step 1
Eye Exam Referral Form
Referring Doctor Name
Clinic Phone Number
Patient Name
Phone Number
Date of Birth:
of appointment
date_range
Reason for Referral:
Dry eye
Tearing eyes
Headaches
Blurry vision
Other
Other Reason for Referral
your full name
OHIP Coverage
pick one!
Diabetes
Paediatric
Senior
Red Eyes
Eye Injury
Submit Form
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MENU
Home
Services
Dry Eye Treatment
Blepharitis
Astigmatism
Far sighted & Near sighted
Cataracts
Red Eye or Conjunctivitis
Hordeolum
Uveitis or Eye Inflammation
Contact Lenses
Diabetes
Glaucoma
Eye Injury
Laser Surgery
Ophthalmologist Consult Referral
Myopia Management
OCT Scan
About Us
Brands
Directions
New Patient Registration Form
Routine Patient Registration Form
Eye Exam Referral Form
Book Eye Exam
Call Us:
905-913-1109
or
Email Us:
drdeolfamilyeyecare@gmail.com
or
Fill the form below:
[]
1
Step 1
Your Phone Number
Your Name
Your Email Address
email
Date of Birth
date_range
Patient Type
Routine Patient
New Patient
Preferred Day of Week
Mon
Tue
Wed
Thu
Fri
Sat
Sun
Best Time for Appointment
Morning
Afternoon
1st preffered Date
date_range
Am
Pm
Anytime
2nd preffered Date
of appointment
date_range
Am
Pm
Anytime
Reason For Appointment
Comprehensive Adult Eye Exam
Comprehensive Child Eye Exam
Eye Redness
Diabetic Eye Exam
Glaucoma Testing & Visual Field Screening
Cataracts Diagnosis & Surgery Co-Management
Laser Vision Consult & Co-Management
Contact Lens Fitting
Ministry of Transportation Driving Vision Testing
Police Vision Testing
Eye Injuries
Dry Eye Syndrome
Comments/Questions
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