Booking an Eye Examination with University of Waterloo School of Optometry & Vision Science (Jan-Apr 2023)

Booking an Eye Examination with University of Waterloo School of Optometry & Vision Science

(Thank you for your interest in booking an eye examination with University of Waterloo School of Optometry & Vision Science. The information that you share below will be shared with the staff and students supporting your child's Eye Exam from the team at University of Waterloo School of Optometry & Vision Science and will also be visible to the EarlyON professionals supporting our booking process. We treat all confidential information with the utmost respect and your information will not be shared beyond with those professionals who require it to support your family and your eye examination appointment.)
This eye examination appointment must be made and attended by the child’s parent or legal guardian. If you would like to book eye examination for more than one child, please submit the form separately. Please complete the form below and a team member will connect with you. A valid Ontario Health Card is required.
Parent/Legal Guardian Name*

First Name Last Name
Email - Your email address will be shared with the University of Waterloo School of Optometry who will send you automated reminders of your appointment time via email. *
example@example.com
Phone Number*
Please enter a valid phone number.
Child Name*

First Name Last Name
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
1. How old is your child? (This appointment is for children from 6 months to 6-year old) ?*

6 months7 months8 months9 months10 months11 months12 months1 year2 years3 years4 years5 years6 years
2. I am the parent or legal guardian of the child and will attend the appointment.*

YesNo
If you answered "no" to the above question, you cannot book this eye exam appointment. You must be a parent or legal guardian of the child listed in question 2 above.
3. Which EarlyON location you would like to book to attend?*
4. Which date you would like to book? (Please choose one only)*
4. Which date you would like to book? (Please choose one only)*
4. Which date you would like to book? (Please choose one only)*
4. Which date you would like to book? (Please choose one only)*
4. Which date you would like to book? (Please choose one only)*
Should be Empty: