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  • Contact lenses require additional testing and evaluation, thus there is an additional fee for our contact lens patients. Our fee for these services ranges from $55 to $105. We will notify you of your exact fee before we provide this service. You have 6 weeks to finalize Contact lens prescription included in this fee.
  • ALL FEES INCLUDING INSURANCE COPAYS ARE DUE AT TIME OF SERVICE
  • The following pertains to your visual symptoms and health history. Please check all that apply.

  • I understand that the benefits quoted to me are not a guarantee of payment and that I am responsible for all of my out of pocket expenses at the time of service. I understand that payment by my insurance company is based on my eligibility and coverage at the time services are rendered. I authorize payment by my insurance directly to Clarion Optometry Group Prof Corp.
  • The signed patient hereby authorized Clarion Optometry Group and associates to use or disclose the patient's PHI to carry out treatment, payment or health care operations on behalf of the patient. I understand the "Notice of Privacy Practices" HIPAA agreement and have been offered a copy of it.
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  • Your wellness vision exam includes a comprehensive assessment of the retina (the back of the eye). Please select the options you would like below.