Patient Consult Request Form

Request a Consult

We accept same day appointments.

Call our office or submit this form.

We accept most major insurance plans including Medicare, Medicaid, and HMO plans.

Patient Name*
Services/Tests Requested*
This field is for validation purposes and should be left unchanged.

Office: 630-225-7247
After hours: 630-225-7247
Fax: 619-326-3920

Downers Grove Location 3825 Highland Ave. Good Samaritan Hospital, Physician Office Building #1, Suite 3F Downers Grove, IL 60659 Phone: 630-225-7247 Fax: 619-326-3920

Call 630-225-7247 or email: info@retinachicago.com
Addison Location 303 W. Lake St. Suite 303 Addison, IL 60101 Phone: 630-225-7247 Fax: 619-326-3920

Call 630-225-7247 or email: info@retinachicago.com

Patient Appointments

group 38

Call us

630-225-7247

group 68

Multiple Locations in the Chicagoland Area

Addison: 303 West Lake Street

Downers Grove: 3825 Highland Avenue

Call us

630-225-7247

Email us

  • * All indicated fields must be completed.
    Please include non-medical questions and correspondence only.
  • This field is for validation purposes and should be left unchanged.

Request an Appointment
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