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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

Optomap Fact Sheet - Under 40

Optomap Fact Sheet - 40+

Optomap Fact Sheet - Spanish - Under 40

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)

Our practice has been working hard on making sure your next visit to our practice is as safe and relaxing as possible. Please be aware we are asking all patients to wear masks during their exams. Please call us to schedule your next appointment and to learn more about our new health and safety protocols.

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