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Yin Eyecareadmin2017-07-06T01:14:26+00:00

Yin Eyecare

Please complete the following information so that we may provide you better serice.
  • MM slash DD slash YYYY
    If 'No' please present your VISION insurance card to the receptionist.
  • If you have HEALTH insurance, please present your HEALTH insurance card. If you do not have vision or health insurance, you may skip the insurance questions below.

    If 'Yes' please present this insurance card also
  • MM slash DD slash YYYY
  • Unless we are a participating provider for your insurance plan, full payment for services is due at the time of the exam. Verifying eligibility does not guarantee payment from your insurance company. Payment in full is required for all materials (glasses and contact lenses) before they are ordered.

  • Signature
  • MM slash DD slash YYYY
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