Patient History

The following conditions are frequently caused by problems with eye coordination, tracking and focusing. Please check any condition that applies to you.

** We kindly request an email address to remind you when it's time for your annual exam, and when your glasses or contact lenses are ready. Due to medical privacy laws, we will not share this with anyone. **

Medical History

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Please list an emergency contact who is not living with you :

Family And Health History

Please note any personal or family history (parents, grandparents, siblings; living or deceased) for the following conditions:
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Account Responsible

Payment is expected when services are rendered, unless other arrangements are made in advance. We do NOT bill patients or their insurance companies. The amount paid to you is related to the amount of insurance coverage that you have purchased. These benefits are specified in your contract, and bear no relationship to the value of our services.

There is a 1 1/2% monthly service charge for balances after 30 days. The patient is responsible for any legal and related expenses involved in the collection of past due accounts.

Credits on materials are issued as store credits only. There are no credits on custom or prescription items. There is a restocking fee for any returned materials. There is a charge for additional tests and contact lens evaluation.

Please note that there is a $35.00 Late Cancellation Fee for appointments that are changed or canceled within 24 hours of your appointment time.
Self Parent Business Manager
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