Name *

First Name

Last Name

Phone Number *

Cell phone preferred

(###)

###

####

Are you a current patient of Wink Eyecare? *

Yes

No

This appointment is for *

Me

My Family - please provide names below

Ages *

Click any/all that apply

19 years and younger

20 - 64 years

65 years and over

Purpose of Appointment *

Click any/all that apply

Eye Exam only

Eye exam and possibly glasses (no pressure to buy but we want to make sure you have enough time and space to browse)

Glasses only as I already have a prescription (again, no pressure to buy if you want to just browse)

Adjustment or repair

Pick up glasses already ordered in advance

Eyedrops

Other (please specify in Message field below)

Consent *

I consent to Wink contacting me by phone, email or text as needed. I understand that Wink is committed to protecting my privacy but cannot guarantee the confidentiality of information routed via webmail services such as Gmail which may store data outside of Canada.