Patient Registration Online Form

• All exam fees to be paid in full on the date of service
• Payment in full or a 50% deposit before an order can be placed
• Balance to be paid when the order is dispensed/li>

We will do all we can to find out what your vision insurance benefits are and what you are eligible for. We will also submit your claim for you. The information given to us by your insurance company, however, is not a guarantee of payment from them.

All orders are final when placed. I understand I am responsible for any charges not covered by my insurance company. I acknowledge that I received a copy of Optical Effects Vision Center Notice of Privacy Practices.