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Springfield Clinic - 1025 South 7th Street - Springfield, Illinois 62703 - 217 528.7541 - 800 444.7541 <image>
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DISCOVER OUR SERVICES
ONLINE CONTACT ORDER FORM
PATIENT DEMOGRAPHICS
First Name: Last Name: 

   
Phone Number:  Today's Date:

   
E-mail Address:

PATIENT EYE EXAM HISTORY

Are you an established patient with Springfield Clinic?   Physician:

Yes     No

 

Dr. Hill     Dr. Krager

   
Dr. Blunk
     
Have you had an eye exam within the past 18 months?    Approximate date of last eye exam:

Yes     No 

  

     
Location of last eye exam:   Do you need to schedule an eye exam?

Eye Shoppe     St. John's Pavilion

 

Yes     No 
     
CONTACT LENS INFORMATION

What quantity would you like to order?   Are you satisfied with your current lenses?

6 month supply    12 month supply
(Additional rebates are available for 12 month supply)

  

Yes     No 
     
Where would you like to pick-up your order?    

Eye Shoppe     St. John's Pavilion

 

Requests for items that are in stock are typically fulfilled within two business days. Requests for items that must be ordered are typically fulfilled within five business days.

All orders submitted are processed within two business days, and someone from our office will contact you at the number listed above. Please call our office if you are not contacted within two business days.
ADDITIONAL INFORMATION

Additional Comments: (125 characters or less)

Disclaimer: This communication form is not intended to be used to seek medical advice. If you are having problems with your vision or your contact lenses, please contact TeleNurse or your physician immediately.

      

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