Request an Appointment "*" indicates required fields To request an appointment, fill in this form. We will then contact you to confirm available appointment times. If this is urgent, please phone us instead of using this form.Please select your patient type* New Patient Existing Patient Appointment Location*Please selectHamiltonCambridgeHuntlyMatamataMorrinsvilleTe AwamutuThamesChoose a DoctorSpecialist in Hamilton*Dr Benjamin HoyDr Bheema PatilDr David WorsleyDr John DicksonDr Michael MerrimanDr Rohan WeerekoonDr Selma MatloobDr Stephen GuestDr Stephen NgDr Ammar Bin SadiqDr Thiyaga KrishnanDr Verona BothaSelect the specialist who treats you.Specialist*Dr John DicksonSpecialist*Dr Rohan WeerekoonSpecialist*Dr Bheema PatilPatient DetailsName* First Last Phone number* Mobile number Email Date of birth*Day12345678910111213141516171819202122232425262728293031Month123456789101112Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Your Address* Street Address Address Line 2 City ZIP / Postal Code As you are a new patient, we will contact you and assign a specialist that best meets your needs. If you already have a preference as to which specialist you would like to see, please mention that here:Reason for this appointment*How long have you had this problem? Past medical history*Attach any additional information or photos (optional)Max. file size: 8 MB.Please send us any relevant attachments such as a photo or document. I give permission for Hamilton Eye Clinic to contact me by Phone* Yes No I give permission for Hamilton Eye Clinic to contact me by Email* Yes No How would you like to be contacted?*If you need an appointment urgently, please phone us instead of filling in this form.CommentsThis field is for validation purposes and should be left unchanged.
