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    All information is secured and in compliance with the California Consumer Privacy Act (CCPA) & Health Insurance Portability and Accountability Act (HIPAA)
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    Please update your current contact info
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  • 4
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  • 5
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  • 6
    • No, I do not use contacts
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  • 7
    Please choose all that apply
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  • 8
    Please let us know if you have any medical conditions
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  • 9
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  • 10
    The FDA categorizes contact lenses as a medical device and requires an annual contact lens evaluation to renew any contact lens prescription. By clicking, you acknowledge that you have reviewed, or had the chance to review, a copy of the office's Contact Lens Policy and agree to its terms.
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  • 11
    ***COIVD SAFETY PRECAUTION: To improve the safety of you and others by reducing your time in the office, all routine eye exams will require a mandatory Optos retinal imaging to your eye health evaluation (reduced fee of $25) *** Valley Optometry Eyecare is committed to providing you with the best eye care using the latest advanced technology available. We perform Advanced Digital Eye Exams w/ Optomap Retinal Imaging to better track your eye health. The additional fee is $30. By clicking, you acknowledge that you have reviewed, or had the chance to review, a copy of the office's Advance Digital Eye Exam Policy and agree to its terms.
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  • 12
    The above information is true to the best of my knowledge. I authorize any insurance benefits to be paid directly to the physician and acknowledge that I am financially responsible for any balance not paid by my insurance company. I authorize Valley Optometry Eyecare Center or insurance company to release any information required to process my claims. I understand that all professional exam fees and sales of contact lenses and optical goods are non-refundable and due at time of services rendered.
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