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BrunswickEye Logo CMYK

BrunswickEye Logo

We are located at 283 Stadium Drive in Defiance

BrunswickEye Logo CMYK

BrunswickEye Logo

We are located at 283 Stadium Drive in Defiance

Home » Contact Us » Appointment Request Form

Appointment Request Form

Due To HIPAA Regulations:

Any minor child under the age of 18 MUST have written consent from a parent or legal guardian in order to be treated at Brunswick Eye and Contact Lens Center. Consent must also include the parent or guardian’s consent for the minor to have Optos Imaging performed at the time of appointment.

Any NEW patient to Brunswick Eye and Contact Lens Center that is a minor child under the age of 18 MUST have a parent or legal guardian present with them at the time of the initial appointment.

Minor children without parental consent or without a parent or guardian present (when necessary) WILL NOT be able to be treated at Brunswick Eye and Contact Lens Center at that time.

Thank You For Your Cooperation.

  • Please fill in the form below to setup an appointment.
  • Please provide a reason for your appointment. Details are stored securely and not sent by email.
  • Please let us know when you would prefer to have your appointment. Our hours are listed on our location page.
    Please let us know if you are a new or existing patient.
  • :
  • This field is for validation purposes and should be left unchanged.