Vision Clinic Appointment

Eye Exam Appointment Registration

Saturday, January 11, 2025 - Gale Community Academy - 7650 N Marshfield Ave. | This clinic is open to people 18 YEARS OR OLDER who do NOT HAVE VISION INSURANCE who either LIVE IN ROGERS PARK or HAVE BEEN REFERRED BY AN AGENCY OR ORGANIZATION. 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.
What language are you most comfortable speaking?*
If "something else" what language?
Name: *

First NameLast Name
E-mail:
example@gmail.com
Phone Number*

Area Code (ex: 773)Phone Number (ex: 338-1234)
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Appointment arrival time (Appointments will last approximately 1 hour)*
Do you have health insurance*

NoYes, private medical insurance (ex: Blue Cross)Yes, MedicaidYes, Medicare
Your age*

18-3435-4950-6465-7980+
Were you referred by an agency or organization?*

NoYes
Name of referring agency or organization*
What is the name of the agency that referred you?*
Do you wear glasses?*

YesNo
I will bring my glasses to my appointment.*

I agree
Do you wear contacts?*

YesNo
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
Should be Empty:

Eye Exam Appointment Registration