Consultation Request
Patient Information
Insurance Information
Dilation Information
Health History

Financial Policy
Consent to Treat Minor
Acknowledgment of Privacy Practice
Authorization to Disclose Health Information
Order Contacts
Medication Refill Request
Dry Eye Questionnaire

Order Contacts

Fill out this order form so we can evaluate your request. We will call you to confirm your payment method & order requirements. If you have any questions, please give us a call.

Full Name

Date of Birth (mm/dd/yyyy)

Phone (xxx-xxx-xxxx)

Patient Status

Which eye(s) are you ordering contacts for

Vision Insurance Info (Optional)
Enter plan provider and your ID #
(Note: Medicaid does not cover contact lenses)

Notes

Captcha:

Enter Letters/Number you see:

OFFICE HOURS

Mon

9:00 - 5:00

Tue

9:00 - 5:00

Wed

Closed

Thu

9:00 - 5:00

Fri

9:00 - 5:00

Sat

9:00 - 12:00

Sun

Closed

Tallmadge Vision Clinic

384 Northeast Ave.
Tallmadge, OH 44278

(330) 633-9190

Tallmadge Vision Clinic 384 Northeast Ave. Tallmadge, OH 44278 Phone: (330) 633-9190 Fax: (330) 633-6899

Tallmadge Vision Clinic proudly serves Tallmadge, OH and the surrounding areas of Cuyahoga Falls, Akron, Kent, Stow, Munroe Falls, Brimfield, Rootstown, North Hill, Hudson, Streetsboro, Ravenna, Lakemore, Merriman Valley and Mogadore.

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