• I understand and agree to pay for services that are considered cosmetic and/or not medically necessary by my insurance company.
• I understand that verification of benefits is never a guarantee of payment from my insurance.
• I understand that I am responsible for any collection charges, interest and/or fees if I do not remit payment on “non-covered” services.
• In the event of nonpayment I will be responsible for any legal or collection fees. The collection fee is a percentage of the total balance turned over to an outside agency. I agree to be responsible for these fees.
• I understand that my eyes may be dilated during examinations.
• I hereby give consent for myself or my child to be seen