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
  • Fireside Eye Care, P.C.

    Shawna Heddinghaus, O.D.

    600 South Eighth Street
    Benld, IL 62009