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
  • Elgin Vision Source

    Tony Jacob, O.D.
    Clayton Rutkowski, O.D.

    1205 West Highway 290
    Elgin, TX 78621