Low Vision Clinic Appointment Request Form

Please complete this form to be contacted for scheduling clinical services at The Chicago Lighthouse. Our team will reach out to you as soon as possible. You can also reach our scheduling team directly at (312) 997-3686 Monday-Friday from 9 a.m – 5 p.m.

Name*

First

Last
Phone*
Email
Type of Visit
Date Preference

MM slash DD slash YYYY
Time Preference
Location Preference
- IL Medical District Chicago
- Northwest Suburbs
- Downtown Chicago
- South Suburbs
- NW Indiana
By submitting this form you acknowledge the risk of sending this information by email and agree not to hold The Chicago Lighthouse liable for any damages you may incur as a result of the transfer or use of this information. The use or transmittal of this form does not create a physician-contact relationship. More information regarding our privacy policies can be found here: Privacy Policy
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Low Vision Clinic Appointment Request Form

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