Skip to main content

Eye Care in Ontario is at Risk. TAKE ACTION OAO white logo

Home » Contact Us » New Patient Contact Form

New Patient Contact Form

  • Welcome (back) to Bolton Optometry Clinic!

    If you are new or if you are a familiar face we need you to update your information. Please complete the following form before your eye examination.
  • MM slash DD slash YYYY
  • Please let us know how you would like us to contact you. You can say All or chose one
    Please let us know if you are bringing a translator with you. We need to know for social distancing.
  • MM slash DD slash YYYY
  • Secondary Insurance

  • MM slash DD slash YYYY
  • MM slash DD slash YYYY