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Answer the following:
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Payment is required at the time services are rendered. A minimum 1/3 non-refundable deposit is required prior to ordering materials, with payment-in-full prior to dispense. Since eyeglasses and contact lenses are custom fabricated for you, orders once placed cannot be canceled and items cannot be returned for refund.
By my signature I certify the information I have provided is true. I understand the above policies and realize I am financially responsible for this account, regardless of any insurance coverage I may have. I agree to pay any collection costs, including reasonable attorney fees, should they be incurred. In the case of a minor patient, I certify that I am the parent or legal guardian and consent to the treatment of said minor.
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