REGARDING INSURANCE: If we are a contract provider for your vision insurance company, we will be happy to bill you insurance for you. If not, it is customary in the vision care profession that the patient is responsible for the entire fee at the time of the exam and the insurance company reimburses the patient. You should attach a copy of your fee slip to your insurance form and send it to your insurance company for reimbursment. If you have any questions, we will be happy to help you. Payment is due upon time of service.
SPECTACLE/CONTACT LENS INFORMATION
Previous contact RX:
PERSONAL HEALTH INFORMATION
PERSONAL HEALTH INFORMATION CONTINUED
Please notate any family history of the following including parents, grandparents, siblings, children, living and/or deceased in the following:
(If patient is under 18 years old, parent signature is required.)
Please note: The office is open 6 days a week but Dr. Cross gives patient care on Wednesdays, and Fridays only.