Skip to content
Patient Registration Forms Logo
Simpson and Mann Child Registrationadmin2018-10-19T19:42:10+00:00

Simpson and Mann Child Registration Form

  • MM slash DD slash YYYY
  • MM slash DD slash YYYY
  • MM slash DD slash YYYY
  • MM slash DD slash YYYY
  • Developmental Milestones
  • We are happy to assist you in the filing of your insurance claim. If your insurance will not pay the anticipated amount, or your insurance pays you directly, we ask that you pay the balance. Office policy calls for payment at the time of service. If eyewear or contact lenses are to be ordered, a minimum 50% deposit is requested and the balance is due upon delivery. We accept cash, personal checks, Visa, and Mastercard. A monthly rebilling fee of $5 is added to all accounts with unpaid balances after 30 days. I have read and agree to all of the provisions of the office of financial policy. I have received/reviewed a copy of the health care information privacy policy for Simpson and Mann Optometry
  • MM slash DD slash YYYY
Powered by 4PatientCare
Go to Top