Request An Appointment

First Name:
Last Name:
Address:
E-mail Address:
Birthdate: Example: 05/08/1963
Main Phone: Example: 309-555-1212
Secondary Phone: Example: 309-555-1212
Vision Insurance: If you don't have insurance, enter NONE
Medical Insurance: If you don't have insurance, enter NONE
Patient's Social Security #:
Primary Insurance Member's Social Security #: If different than patient's Social Security Number.
Primary Insurance Member's Date of Birth:
Do you have a personal history of diabetes? YES NO

FIRST CHOICE


Appointment Date:
Appointment Time:

SECOND CHOICE


Appointment Date:
Appointment Time:

THIRD CHOICE


Appointment Date:
Appointment Time:

Other Comments:

Upon submitting your appointment request, you will receive an email with a date and time that most closely matches your request. If this appointment is satisfactory, confirmation is NOT necessary. If there is a conflict with the appointment, please call our office as soon as possible to reschedule your appointment: 309-454-2472. This will allow other patients requesting this time to see our Doctors.

Please remember to bring all current glasses and contact lens information. Also bring both your medical and any vision insurance cards.

Because Diabetes is the leading cause of blindness, all diabetic patients will be dilated. If you have Diabetes, please bring a driver. Remember, dilating the eyes may also affect reading and computer vision for up to 5 hours. We do provide reversal medication to quicken this recovery.

We look forward to serving you at your upcoming visit.