BELLINGHAM - MONICA REG TRAINING 3

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  • DR. GLENN D. GREEN

    Optometric Physician


    WELCOME TO OUR OFFICE


  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY
  • (IF STUDENT, LIST GRADE, SCHOOL, AND TEACHER)
  • (FOR CHILDREN UNDER 18)
  • If your insurance is not listed above, we would ask that payment be made when services are rendered. We will provide an insurance bill that you can send in to your insurance company for reimbursement.

  • I understand that I am responsible for payment of any charges not covered by my insurance. I authorize payment of health care benefits to this clinic. I also authorize release of any medical records necessary to process any claims.


  • Full payment for services, glasses and contacts is due when received. THANK YOU.