Vision Clinic Appointment

Eye Exam Appointment Registration

Saturday, January 11, 2025 - 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 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
Name of referring agency or organization
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