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Simpson and Mann Optometry Adult Registrationadmin2018-10-19T19:40:44+00:00

Simpson and Mann Adult Registration Form

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    Check all that apply to you
    Check all that run in your family
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  • PAYMENT TERMS: 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 the provisions of the office financial policy I have received/reviewed a copy of the health care information privacy policy for Simpson and Mann Optometry
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