Appointment Request Form

Monday: 9:00 AM - 7:00 PM
Tuesday: 9:00 AM - 6:00 PM
Wednesday: Closed
Thursday: 9:00 AM - 6:00 PM
Friday: 9:00 AM - 7:00 PM
Saturday: 8:00 AM - 2:00 PM
Sunday: Closed

Name: Visual Symptoms Treatment Center
Address: 3250 N. Arlington Heights Rd, Ste 109, Arlington Heights, IL, 60004, US
Telephone: 847-255-1040
Price range: $000 - $300

Please fill in the form below to setup an appointment.
Reason for Appointment
Please provide a reason for your appointment. Details are stored securely and not sent by email.
Preferred Date & Times*
Please let us know when you would prefer to have your appointment. Our hours are listed on our location page.
Patient Type*
- New patient
- Returning patient
Please let us know if you are a new or existing patient.
Name*
First Last
Phone*
Email*
How did you hear about us?*
Who referred you?*
Best Time to be Reached for Confirmation*

: Hours

Minutes

AM/PM
Comments
Comments
This field is for validation purposes and should be left unchanged.