PORTAL

★ REVIEWS

APPOINTMENT REQUEST

ORDER CONTACTS

EMERGENCY

3117 Dundee Rd.

Northbrook, IL 60062
(847) 562-2010

Patient Information
Insurance Information
Health History

Consent to Treat Minor
Acknowledgement of Privacy Practice
Authorization to Disclose Health Information
Order Contacts

Order Contacts

Fill out this order form so we can evaluate your request. We will call you to confirm your payment method & order requirements. If you have any questions, please give us a call.

Full Name

Date of Birth (mm/dd/yyyy)

Phone (xxx-xxx-xxxx)

Patient Status

Which eye(s) are you ordering contacts for

Vision Insurance Info (Optional)
Enter plan provider and your ID #
(Note: Medicaid does not cover contact lenses)

Notes

Appointment Request

OFFICE HOURS

Mon

10:00 - 5:00

Tue

10:00 - 7:00

Wed

10:00 - 2:00

Thu

10:00 - 7:00

Fri

9:00 - 3:30

Sat

9:00 - 1:00

Sun

Closed

*Closed for lunch 1:00 - 2:00
**Alternating every other Wednesdays and Saturdays

Northbrook Family Eye Care

3117 Dundee Rd.
Northbrook, IL 60062
(847) 562-2010
Map It
Email Us

Northbrook Family Eye Care 3117 Dundee Rd. Northbrook, IL 60062 Phone: (847) 562-2010 Fax: (847) 562-2012

Northbrook Family Eye Care proudly serves Northbrook, IL and the surrounding areas of Deerfield, Wheeling, Buffalo Grove, Highland Park, Arlington Heights, Mt Prospect, Des Plaines, Glenview, Skokie, Evanston, Palatine, Prospect Heights, Schaumburg, Glencoe and Elk Grove Village.

Internal email | Internal forms