Optical Agreement

Optical Agreement
By signing this agreement, I understand that my vision appliances will be placed on hold until payment from my insurance is made.

I understand that if I cannot wait, I can pay in full myself and be reimbursed accordingly by check or credit card when the insurance payment is made.

I also understand that my insurance may take up to 3 months to pay for my glasses and I am responsible to update my insurance information.
I certify that I did not recieve a pair of prescription eyeglasses or contact lenses within the last 24 months.*

YesNo
I certify that I did not have an eye examination (refraction) within the last 24 months. (12 months for children age 20 or younger).*

YesNo
I have read and understand the above conditions and I will comply with the accordance and contents.
Signature of Parent or Legal Representative*

Clear
Patient's Name*

First NameLast Name
Patient's Date of Birth*

MonthDayYear
Date*

MonthDayYear
If patient is a minor, unable to sign or without decision making capacity, relationship of person authorized to consent must be stated.
Name of Legal Representative

First NameLast Name
Relationship to Patient
Should be Empty: