Family Eye Care VSP

  • Date Format: MM slash DD slash YYYY
  • Medical Information

  • Family History

  • Personal Eye Information

  • Consent for Treatment

    Dr Kirk Kvitle / Dr. Jason Kvitle are hereby authorized to render services, medication and treatment as necessary. I assume full financial responsibility for any bills incurred. Dr Kirk Kvitle / Dr. Jason Kvitle are participating Medicare providers.
  • Insurance Release

    l authorize the release of medical information contained my medical records to family physicians and / or insurance companies. A photocopy of this authorization shall be as valid as the original. I assume responsibility for any balance above insurance.
  • Late/No Show Policy

    It is the policy of Family Eyecare & Contact Lens Center, LLC that if a patient misses more than three (3) appointments in 1 year without calling to cancel, they will be made walk-in only. A patient is considered "LATE” if they are more than 15 minutes late for their scheduled appointment. It is at the discretion of the provider as to whether the patient can still be seen as they will need to reschedule.