Is this appointment for yourself or someone else? *

Self

Another Person

Patient First Name *

Patient Last Name *

Patient Date of Birth *

Contact First Name *

Contact Last Name *

Email *

Phone *

Preferred Communication Method *

Phone

Email

Best time to talk via phone? *

7:30 am - 9:30 am

9:30 am - 11:30 am

11:30 am - 1:30 pm

1:30 pm - 3:30 pm

3:30 pm - 5:00 pm

No Preference

New Patient *

Yes

No

Address *

City *

State *

Postal code *

5-digit or 9-digit acceptable

Vision Plan Provider

Illinois Eye Center cannot assist you in verifying in-network status without accurate, up-to-date vision plan information.

Which office would you like to be seen at? *

Peoria

Washington

Pekin

No Preference

What days of the week work best for your appointment? *

Monday

Tuesday

Wednesday

Thursday

Friday

No Preference

What times of day works best for your appointment? *

8 am - 10 am

2 pm - 4 pm

10 am - 12 noon

No Preference

12 noon - 2 pm

I agree to terms & conditions provided by Illinois Eye Center. By providing my phone number, I agree to receive text messages from Illinois Eye Center. *

UTM Campaign

UTM Medium

UTM Source

Back to school exams and special offer are available to patients 18 and under.