New Patient Form

COVID-19 Waiver
By signing this form you acknowledge that you do NOT have any of the following symptoms or have done any of the following activities.
I have not been in close contact with or cared for someone diagnosed with COVID-19 within the last 14 days.
I have not experienced any of the following cold or flu-like symptoms in the last 14 days: - excessive cough, fever, sore throat, shortness of breath

Eyeglass Purchases & Contact Lens Wearers
Please be advised if you would like a prescription for contact lenses, you are responsible for a contact lens examination every year which includes 90 days of follow up care. This fee is an addition to your glasses examination & varies depending on the type of contact lens fitted and is assessed by the doctor during your examination. Glasses purchased have a 90 day remake policy from date of purchase for lenses only. A 25% restocking fee will be assessed for all cancelled orders.

Financial Responsibility
I authorize payment of my medical benefits to the undersigned physician / supplier for services rendered and/or products provided. I understand that Cedar Park Eye Care will make every effort possible to bill my insurance company and obtain all the necessary information for proper billing in advance of the services. I also understand that if Cedar Park Eye Care is unable to obtain authorization from my insurance company or if my insurance company fails to cover the services and materials, I WILL BE PERSONALLY FINANCIALLY RESPONSIBLE FOR SERVICES RENDERED AND PRODUCTS DELIVERED AND/OR PROVIDED. I am responsible for all accounting fees in the event of my non-payment. There is a $50 no-show and cancellation policy in effect if no notice given within 24 hours of your visit and $50 returned check policy.

Annual Contact Lens Agreement
- If your Rx changes, we will exchange contact lenses purchased from us. Boxes must be resalable, i.e. no marks, no writing, no torn or missing labels and must be factory sealed.
- Contact Lenses are medical devices which should be monitored by the doctor to determine the current prescription and health of the eyes to ensure successful contact lens wear.
- I understand that annual exams and sometimes 6 month corneal evaluations are necessary to continue replacing contacts.
- I understand that there is an increased risk of infection, corneal ulcers that can lead to loss of vision or blindness with contact lens wear. The risk increases significantly if the contacts are worn while sleeping, either 10 minutes or 10 hours. Complying with wearing times, care regimens and disposal schedules minimize this risk.
- I understand that if sudden or prolonged redness, pain or irritation of the eyes occurs, I should remove the lenses and call this office immediately.
- I understand that topping off the solution in my case every night instead of replacing it can lead to permanent vision loss.