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Demographic Form

  • Patient Information

  • Date Format: MM slash DD slash YYYY
  • example@example.com
  • The following information is optional and is being gathered to ensure that all patients receive the best care possible.
  • Guarantor (Person Responsible for Insurance / Billing) Information
  • Date Format: MM slash DD slash YYYY
  • Insurance Information

    Please fill out as completely as possible
  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY
  • Financial Policies (Insured and Non-Insured)

  • All service fees and co-payments are due when services are rendered. We will file claims for services rendered to the appropriate insurance payer in good faith. All medical eye care is subject to any insurance deductible. It is the patient's responsibility to know the specifics of the insurance plan and to pay any amounts applied to the patient deductible. Any unpaid balances that are left after 90 days will be subject to a monthly $5.00 late fee and additional service fee of up to 35% of your balance, if sent to collections. A minimum of 50% DOWN PAYMENT is required on all materials to start your order. Any balance will be due upon the dispensing of your eyewear. NO CASH REFUNDS ON MATERIALS.

    CONTACT LENSES are medical devices requiring additional evaluation to ensure proper eye health, vision, and comfort. The fee for these services is not included in other eye care provided and varies with the contact lens type and complexity of the professional service. This fee starts at $84 and is most often not fully covered with vision insurance or other insurance plans. Fees for professional services are due in full on the service date and contact lens materials require a minimum 50% deposit to order. No contact lens prescription can be released until the lenses are finalized, which may require a mandatory follow- up visit. Please ask for any clarification needed about the policy on contact lens materials or services.

  • Date Format: MM slash DD slash YYYY
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