Membership Application Form

griswold eye care vision membership

Thank you for signing up for our membership plan at Griswold Eye Care. Please select the plan you would like below. The benefits will be good for one year from date of sign up.Please don’t forget you can call us or text us for any needs- urgent or routine.
Name*

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
E-mail
example@example.com
Cellular Number
Membership Type
prevnext( X )
Lilac Plan25% off glasses + 50% off non-rx sunglasses, 20% off contact lenses, no exam coverage but still priority scheduling, $40 contact lens exam fee.
$100.00



Violet Plan1 Comprehensive Eye Exam per year which includes a retinal photo, $50 urgent care visit, priority scheduling, $40 contact lens exam fee, 25% off glasses, 20% off contact lenses and 50% off non-prescription sunglasses.
$280.00



Amethyst Plan1 Comprehensive Eye Exam per year which includes a retinal photo, $50 urgent care visit, priority scheduling, 25% off glasses & 20% off contact lenses, 50% off non-prescription sunglasses, 6 sessions of dry eye therapy in office of your choosing per year (Thermal One Touch or Low Level Light Therapy- up to $600 value) and 25% discount on additional dry eye in office treatments.
$600.00



Total

$0.00
Please Also select how you would like us to proceed regarding any medical visits:

I would like to have my medical insurance billed and understand I am responsible for copays/co-insurance/deductible amounts.I do NOT want my medical insurance billed. I will pay the $50 urgent care visit fee if and when applies.
Once you have submitted your application, please give our office 2-4 business days to reach out for payment and approval.
Date of Membership Start:

MonthDayYear
Date
Billing Adress

Use the address above.I want to specify a different billing address.
Billing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Signature*

MonthDayYear
Date
Signature*

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griswold eye care vision membership