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BENSENVILLE
EYE CARE

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BENSENVILLE EYE CARE

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Patient Forms

Please fill out the new patient form and then hit the submit button to send the information directly to our office. This information provides us with your health history and other information related to providing you with the best eye health and vision solutions.

New Patient Form - Submit Online

New Patient Form (Spanish) -  Download & Print

HIPAA (English) - Download & Print

HIPAA (Spanish) - Download & Print


Payment Options

Bensenville Eye Care has products and pricing to accommodate all budgets for your eye care and eyewear needs, including eyeglasses, contact lenses, routine office visits and medical office visits. Our office accepts:

  • Cash
  • Check
  • Visa, MasterCard and Discover
  • CareCredit
  • Flexible Spending Plans
  • Health Savings Accounts (HSA)
  • Medical Savings Accounts (MSA)

Under the advisement of the CDC, we are rescheduling our routine eye care appointments and offering Telehealth for emergent issues that may not need to be seen face-to-face. We will be scheduling Telehealth emergency appointments for video consultations with our doctors for patients in need of non-routine eye care. Please call 847-254-9665 to set up a video consultation. We will try to see your eye care emergencies if we can. If we can't help with your eye emergency, you should go to your local emergency room.

We are prepared to navigate these unique and challenging circumstances with the health and safety of our patients and employees as our focus. And because of that commitment, we have made the difficult decision to temporarily close effective March 23, 2020. We will continuously evaluate when to re-open based on recommendations from local, state, and federal health officials. We love this community. We love connecting with each of you and serving you. We love our team. Right now, our commitment is putting everyone's health first, but we look forward to opening our doors again as soon as possible. We appreciate your patience with us as we try to do what’s best, healthy and safe for our patients, employees, and community.

Thank you for being a valued Bensenville Eye Care patient.