Who is this appointment for? *

Self

Another Person

Is the patient new to Illinois Eye Center? *

Yes

No

What type of appointment are you requesting? *

Has the patient had a valid vision exam in the past 12 months?

Yes

No

Valid prescription (past 12 months) required to order glasses or contacts. If you don’t have one, please schedule a vision exam below. Not needed for adjustments, cleaning, issues, or pickups.

Patient First Name

Patient Last Name

Patient Date of Birth

Please format mm/dd/yyyy

Patient Address

Patient City

Patient State

Patient Zip Code

Contact Information

Contact First Name *

Contact Last Name *

Contact Email *

Contact Phone *

Date of birth

Please format mm/dd/yyyy

How should we contact you? *

Phone

Email

When is the best time to talk via phone?

7:30am - 9:30am

9:30am - 11:30am

11:30am - 1:30pm

1:30pm - 3:30pm

3:30pm - 5:00pm

No Preference

Appointment Information

Please schedule your vision exam

Vision Plan Provider

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

Medical Insurance Provider

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

Optical Options

Preferred Optician

Office Preference

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?

8am - 10am

10am - 12pm (Noon)

12pm (Noon) - 2pm

2pm - 4pm

No Preference

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. *

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