Patient Information

Name (Legal) *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

(###)

###

####

Date of Birth *

MM

DD

YYYY

Gender

Female

Male

Other

Subscriber Name

First Name

Last Name

Subscriber Date of Birth

MM

DD

YYYY

Financial Agreement: I agree to take full financial responsibility for all charges incurred for services rendered. For those with claims that will be billed to medical or vision insurance plans: I understand that I am responsible for any services not covered by my insurance plan. (If you have questions about your coverage, please contact your insurance company). *

I understand and agree

Financial Agreement: I understand that all exam fees (including contact lens fees) are non-refundable. If a prescription re-check is required, it must be done within 3 months of the original exam date. *

I understand and agree

HIPAA Notice of Privacy: I have seen a copy of the HIPAA Notice of Privacy Practices from SpecialEyes Eyecare and/or I am aware a copy of the practices can be provided by request or viewed online below *

I agree

Contact Lens Exam Agreement: I understand that the Contact Lens exam/fitting is not included in the regular Routine Eye Exam. An additional fitting fee will be charged that may not be covered by my insurance which I am responsible for paying. I have read, understood and agree to all the terms of the Contact Lens Exam Policy which can be viewed online below. *

I understand and agree

No, I am not interested in being fit for contact lenses today

Each time an appointment is missed without providing prior notice, another is prevented from receiving care. Recognizing that everyone's time is valuable, I agree to provide a minimum of 24hrs notice if I am unable to keep my appointment. All appointments cancelled or rescheduled without 24 hours notice are subject to $50 fee. *

I agree