MM slash DD slash YYYY
Personal Eye Information
Consent for Treatment
Dr. Kristie Chevalier is hereby authorized to render services, medication and treatment as necessary. I assume full financial responsibility for any bills incurred. Dr. Kristie Chevalier is a participating Medicare provider.
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.