Appointment Request Form

Name: Dr Hopkins & Associates Optometry – Niagara on the Lake
Address: 358 Mary St., Niagara-on-the-Lake, ON, L0S 1J0, CA
Telephone: (905) 468-8002

Please fill in the form below to setup an appointment.
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 on our location page.
Patient Type*
- New patient
- Returning patient
Please let us know if you are a new or existing patient.
Name*
First Last
Phone*
Email*
Best Time to be Reached for Confirmation*

: Hours

Minutes

AM/PM
Comments
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Appointment Request Form

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