Heartland
Optical
Call us today to schedule
your appointment:
(402) 476-3311
1012 North 27th Street | Lincoln, NE 68503
EMERGENCY
APPOINTMENTS AVAILABLE
Contact Us -
402.476.3311 heartlandoptical@gmail.com
Schedule Your Appointment by Filling Out the Form Below
Please feel free to contact us at 402.476.3311 to schedule an appointment or use the form below to request an appointment and we will contact you with your scheduled time. Also, please call or email us with any questions you may have regarding eyeglasses and/or contact lenses.
First Name:
Last Name:
Address:
City:
State:
ZIP:
Personal Information
Home Phone:
Cell Phone:
Email Address:
Date of Birth:
Do you have insurance?
If yes, what is the name of your insurance company?
Vision Insurance Information
Patient History & Appointment Preferences
Have you visited us in the past?
Preferred Appointment Date:
Preferred Appointment Time:
What is the purpose of your appointment?
Example: blurry vision, red eye, discomfort, regular exam, etc.
What is your Insurance ID Number?
Heartland Optical accepts many insurance providers. Click here to view the list of accepted insurance providers.
Copyright 2011 Heartland Optical
