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

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

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  • 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

    419-334-8121

    622 Parkway Dr
    Fostoria, OH 44830

    419-435-3482