We strive to provide the highest level of professional eye care in a friendly and caring
environment and to maximize our patients' quality of life; utilize the most advanced
technology and professional skills; and inspire confidence through patient education.
I consent to the use and disclosure of my health information for the purposes of treatment, payment, and health
care operations. In addition, I give my permission for your office to leave telephone messages confirming
appointments and any other related office matters.
If you are signing as a personal representative of the patient, describe your relationship to the patient.
Professional fees are due when services are rendered unless prior arrangements are made. A deposit of 50% is
required toward the total cost of glasses before an order can be placed. The remaining balance is due at the time of
dispensing. When eyeglasses are purchased through insurance, the balance is due in full when the order is placed.
When ordering contact lenses, total payment is due before the order can be placed, unless otherwise specified. Thank
you for your cooperation.