New Patient Intake Form – Step 3

CONTACT LENS INFORMATION (Please skip this box if you do NOT wear contacts)

1. 
   (if not known, please check which types):
   SoftHard/Gas PermeableDisposableMonovisionBifocalColored

I authorize this office to release any information to third-party payers for billing purposes. I authorize and request my insurance company to pay my insurance benefits to Accent Eye Care. I acknowledge that I am financially responsible for any services/materials and claims not covered and /or denied by my insurance for myself and my dependents. Returned checks incur a
$30 fee. Appointments not cancelled within 24 hours are subject to a $30 fee. Accent Eye Care is not responsible for previously used frames and/or lenses which are being reused or adjusted at my request. Eyeglass lenses and frames are non-returnable and non-refundable medical devices. Eyeglass frames are warranted only for manufacturer’s defects one time within one year of purchase; shipping, handling and restocking fees will apply. Prescription accuracy is warranted and must be reported within 60 days from date of exam with a one time redo of lenses purchased here. Unmarked and unopened contact lens boxes may be exchanged within 60 days from date of exam; a restocking fee will apply. Contact lens fittings are non-refundable. I understand that all fees may be subject to change without notice. Any balance owed by you or the guarantor is subject to a 1.5% late fee (18.0% annum) to be assessed monthly until we receive payment in full. If the account is referred to a collection agency there will be a collection fee of up to 30% over the principle assessed and any applicable fees.