4010 Velo Eyecare Reg Form

  • Date Format: MM slash DD slash YYYY
    We do not share your phone numbers.
    We do not share your email.
  • Please choose one.
  • There are fees to evaluate and update a contact lens prescription. I understand that these fees are not covered by most insurance, vision, or managed care plans as it is not considered part of a routine eye exam. I will notify the staff if I decide not to have this service performed. I understand and agree that health insurance policies are an arrangement between an insurance carrier and myself. I authorize payment from my insurance carrier direct to this office with the understanding that all monies will be credited to my account of receipt. However, I clearly understand and agree that all services rendered are charged directly to me and that I am personally responsible for payment. I also authorize release of any medical information that may be required in determination of benefits. I have received a copy of Vision Source's Privacy Statement.
  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY