Name *

First Name

Last Name

Phone Number *

Cell phone preferred

(###)

###

####

This Appointment is for

Check all that apply

Me

My family - please provide names below

Ages *

Check any/all that apply

19 years and under

20 - 64 years

65 years and over

Purpose of Appointment *

Check all that apply

Complete eye exam only

Complete eye exam AND glasses from Wink (additional time will be allocated with an optician or frame stylist)

Glasses only as I already have a prescription

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 sent by email/text as communication sent via webmail services such as Gmail may be stored/routed outside of Canada.