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  Schedule an Appointment
What to bring to your appointment:
  • Your glasses and contact lenses
  • Your contact lens boxes that list your prescription
  • A complete list of your medications
  • If you are scheduled to have a dilated eye exam, you may want to bring sunglasses and someone to drive you home.

Scheduling your appointment on the Internet:

The Imler Eye Clinic is offering this "Schedule an Appointment" form for people who don't have time during our regular business hours to call in and schedule an appointment. Please fill out all the information below and press the submit button once.

 
Your appointment won't be officially scheduled until a representative from our office either emails or calls you to confirm your appointment. If you have not heard from us within two business days, please call.
Patient Information
First Name   * Last Name   *
Day-Time Phone   * Email Address   *
Address   * Apt #
City   * State & ZIP
  *   *
Date of Birth
month day year
*  
Have you been to the Eye Clinic Before
yes no
If this is your first visit, how did you hear about us?
If you have, how long has it been since your last visit?
Reason for Appointment
Is this a routine eye exam?
yes no
What (if any) specific problems are you experiencing?
Do you wear contact lenses?
yes no
Scheduling Information
What days are convenient for you?
  *
What Times are convenient for you?
  *
How would you like us to confirm your appointment ?
Email Day time phone
Insurance
As soon as you are able, please have your vision and medical Insurance information available.
We will ask for this when we contact you.
Privacy Policy
The information you supply via this appointment form is considered strictly confidential and will never willingly be shared with anyone without your explicit permission. Some people are concerned about information on the Internet being “hijacked” by hackers. This concern may be valid not only for the Internet, but for any communications by any method, be it wireless telephone, a cell phone, a FAX machine or any other communications device. Although this web page is protected by 128 bit encryption security, The Imler Eye Clinic, LLC cannot guarantee the security of the information you submit using this form as it pertains to electronic transmittal. If you deem the information we ask for to be sensitive, the only way to ensure its absolute security is to discuss it with the doctor face-to-face. We encourage you to do so by requesting an appointment by phone.
I have read and accept the privacy policy I DO NOT accept the privacy policy and would rather call
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Copyright © 2010 The Imler Eye Clinic of Rockford, LLC. All rights reserved.
4857 Manhattan Drive. Rockford IL 61108 | Phone (815) 399-0599 Fax (815) 399-2499