Appointment Request Form

Vision Insurance/ Insurance (if any):
Insurance Number:
I would like an appointment with:

Please select up to 3 appointment dates / times.
If you can't find a convenient appointment time, please call our office

Enter Letters Shown

Please Note: The requested appointment time(s) may no longer be available. We will contact you to confirm your actual appointment date and time.

Practice Photo
  • Eye Centers of Northwest Ohio - Fremont

    Greg DeRodes, O.D.
    Stacy Rellinger, O.D.
    Jason Kolodziejczyk, O.D
    Susan E. Smith, M.D.

    2311 Hayes Avenue
    Fremont, OH 43420


    622 Parkway Dr
    Fostoria, OH 44830