OptiLand - Book Your Eyeglass Appointment Online

Use this page if you would like to visit Opti-Land.
(Dr. Piper and Dr. Treadway)

Use this form to request an appointment 48 hours or more in advance. If you need to get in sooner, please call Opti-Land at 869-3937 or the Spec Shop at 882-3937.

Contact Information *Indicates Required Field.
*First Name:
*Last Name:
Nick Name:
*Patient Date of Birth:	Month Date Year
*Responsible Party if Patient is a Minor: (Full Name)
Would we know you by any other name?
*Email Address:
*Daytime Phone:
Work Phone:
Mobile Phone:
*Street Address:
Apt or P.O. Box:
*City:
*State:	*Zip:
Patient Information All Fields Are Required.
Have we had the opportunity to serve you before?
Is this exam for eyeglasses or contact lenses?
Which day of the week would you prefer? (Check all that apply)	Monday Tuesday Wednesday Thursday Friday Saturday
What time of the day would you prefer?
Do you have a doctor preference?	If Other, Please Specify Doctor Name: Doctor Phone:
Do you have a doctor preference?	Please Note: You can request an appointment with your own doctor using this form and still come to Opti-Land to save 50% on frames and lenses. Heffington Optical will be glad to call and set up an appointment. However, we cannot guarantee the availability of appointments with another doctor.
Will you be using vision insurance?
If Yes..	Member Name ID# Group/Plan Insurance Verification Phone
Please check all that apply.	Medicare Medicaid MC+
Questions or Special Instructions?

640 West Chestnut Street
Springfield, MO 65802
Phone 417-869-EYES (3937)
Fax: 417-869-0281
Toll-Free 1-800-892-2020

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