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Eye Exam Appointment Registration
Saturday, March 2, 2024 - Gale Community Academy - 7650 N Marshfield Ave. | This clinic is open to RESIDENTS OF ROGERS PARK, 18 YEARS OR OLDER who do NOT HAVE VISION INSURANCE. Rogers Park boundaries are: W. Devon Ave to W. Howard St. (unless in the North of Howard community) and the lake to N. Ridge Blvd. The ZIP codes are 60626 with a tiny sliver of 60645.
Name:
*
First Name
Last Name
E-mail:
example@gmail.com
Phone Number
*
-
Area Code (ex: 773)
Phone Number (ex: 338-1234)
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Appointment arrival time (Appointments will last approximately 1 hour)
*
Do you have health insurance
*
No
Yes, private medical insurance (ex: Blue Cross)
Yes, Medicaid
Yes, Medicare
Your age
*
18-34
35-49
50-64
65-79
80+
Were you referred by an agency or organization?
*
No
Yes
Name of referring agency or organization
Do you wear glasses?
*
Yes
No
I will bring my glasses to my appointment.
*
I agree
Do you wear contacts?
*
Yes
No
I will not wear contacts to my appointment.
*
I agree
I acknowledge that my eyes will be dilated as part of my appointment.
*
I agree
Submit Form
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