Patient Consent Form

To expedite your registration process, we are offering online registration forms for your convenience. Please feel free to complete these forms prior to your scheduled visit - so that you do not have to complete them upon your arrival.
  • We will make every effort possible to bill your exam to your health or vision insurance. However, if your claim is denied and we find ourselves unable to process the claim further, it is the patient responsibility to pay any balance due. I understand that non-payment of my balance will place me at risk of being reported to a collection agency.
  • As part of our comprehensive exam, our optometric technicians will take photos of the back of the eye for all of our patients. These photos provide the doctors with a great deal of information regarding the health of one's eye.In some cases, it can even be an alternative to having your eyes dilated. These photos, however, are sometimes not covered by health or vision insurance and are an additional $40 charge. The charge will only be incurred if the patient wants the doctor to interpret the results. If you choose not to have the results interpreted, the doctor may choose to dilate your eyes.
  • We like to assist our patients in every way possible. This is why we automatically set up your annual eye exam for you. If this is a service you do not wish to receive, please indicate in the box below.