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100 MILE VISION CARE

Home » Contact Us » Appointment Request Form

Appointment Request Form

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

To request your next appointment, please complete the form below and let us know the most convenient time and date for you.  Please don't forget to include accurate contact details so we can follow up with you to finalize your request.

  • Request Date & Time


    Please select your preferred date with a second, and third option. We will do our best to book you on your requested date but please note that we usually book 2-3 weeks in advance.

    Optional: Select the days of the week that would work best for you if your preferred date is not available.

    Please note that although our office is open during our lunch hour, we do not offer appointments between 1:00 pm and 2:00 pm.
  • Personal Details


    Please fill out as completely as possible. Details are stored securely and not sent by email.

  • This field is for validation purposes and should be left unchanged.