Consent for Care and Billing

Consent for Care and Billing
Thank you for choosing Professional VisionCare for your vision and eye health needs. Please read the following statement, and sign below to indicate your consent to these policies.

CONSENT TO TREATMENT:
By my signature below, I do hereby voluntarily consent to treatment provided by Professional VisionCare for my eye care appointment.

INSURANCE BILLING POLICY:
By my signature below, I understand that Professional VisionCare will bill my vision benefits plan and/or medical insurance on my behalf for any services of care I receive at Professional VisionCare. I also understand and agree that I am financially responsible for any co-pays, deductibles, and/or co-insurance not covered by my medical insurance.
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If you do not consent to care from Professional VisionCare or our billing policy, you do not have to sign this form and can check the box below. We will be unable to see you for your appointment if you do not consent.

I do not consent to treatment and billing.
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