Online Patient Form

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Patient Information

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Custom Eyes Release and Assignment

I hereby authorize Custom Eyes to release my insurance carrier all information concerning my illness and treatment and hereby assign Custom Eyes all payments for medical services rendered to myself and/or my dependents. I understand that I am fully responsible for any amount NOT covered by my insurance carrier.

Receipt of Notice of Privacy Practice Written Acknowledgement Form

My signature confirms, I have been informed of my rights to privacy regarding my protected health information, under the Health Insurance Portability & Accountability Act of 1996 (HIPAA). I understand that information can and will be used to:

• Obtain payment from third-party payers for my health care services. I have been informed of my provider's Notice of Privacy Practices containing a more complete description of the uses of disclosures of my protected health information. I have been given the right to review and receive a copy of such Notice of Privacy Practices. I understand that my provider has the right to change the Notice of Privacy Practices and that I may contact the office to obtain the Notice of Privacy Practices.

• Provide and coordinate my treatment among a number of health care providers who may be involved in that treatment directly and indirectly. I understand that I may request in writing that you restrict how my private information is used or disclosed to carry out treatment, payment of healthcare operations, and I understand that you are not required to agree to my requested restriction, but if you do agree then you are bound to abide by such restrictions

Authorization to Release Medical Records

I hereby authorize Custom Eyes to release any and all information related to my past and present medical history, diagnoses, and treatments to my specialist that will be treating me during my treatment. I understand that any records not related to my condition and treatment will not be released.

Financial Responsibility

I understand that I am personally responsible for any medical fees I will incur at Custom Eyes. I also understand that I will be responsible for any charges incurred by not providing the most current, correct insurance information to Custom Eyes. I understand that I am responsible for any payments that may include my deductible (if not already satisfied), any co-payments, and any remaining portion of the bill (materials, add-ons, etc.) that is not covered. I understand I am financially responsible for services received from Custom Eyes.

I approve an additional/optional OCT test for $40 which screens glaucoma, diabetes and high blood pressure of the eye.

CustomEyes Policies

CustomEyes of Pearland is centered on providing exceptional eye care to our patients. This includes frames, contact lenses, and accessories that are medically sound and fashionable to meet today's patient expectations. CustomEyes strives to be the choice provider for total eye care and customized eye solutions for the community. CustomEyes is committed to promoting ocular health and beauty to every patient it serves.

These options will warranty your lenses for one year against scratches from normal wear and tear. We will need the original lenses to send back to the lab, allow 7-10 business days. Warranty fee is $25 and covers one time within one year from original purchase date.

Most of our frames are warranted for one year for manufacturing defects beginning with the original purchase date. The warranty fee is $25. This warranty does not cover stepped on, dropped, chewed on, lost, or other accidental breakage. Frames have a one time warranty . Please DO NOT attempt to repair broken frames. Any use of super glue or bonding agent will void warranty from the manufacturer.

All contact lens exams/fits should be done within 90 days of receiving glasses prescription or we will need to have the optometrist perform a prescription check (refraction) which is $35. Only contacts that have been prescribed by the doctor will be approved to order. If you want to order a different brand or type of contact you will need to schedule an appointment for a contact exam/fit. All contact supplies must be paid in full before they are Ordered.

We will not be able to hold contacts and glasses that have not been picked up within 180 days (6 months) from the date of the order.

Prescriptions that have increased or decreased in power would need some adapting period. If you are unable to adapt after two weeks of wear time, please contact us. If necessary, an appointment will be made for you to come in to meet with the optician and/or the optometrist to determine if any changes are needed. The lab will only allow a one-time remake within the first 90 days of the original purchase date.

For first time progressive wearers, we will work with you on learning how to use your new progressives. Please allow yourself 2-3 weeks for successful adaptation. After trying the progressives and are still unable to adapt, we can do a one time remake. This is a 90 day warranty from the original purchase date. Unfortunately, we are unable to refund original purchase price for the lenses; we can however, completely remake your single vision lenses at no additional cost.

Frame returns within 14 days with 30% restocking fee, not including lenses. NO refund on lens charges. Frame exchange within 7 days, 30% restocking fee, no refund on lens materials. No refunds on loss of materials that are not picked up within 90 days. No exceptions.

There are a few things that we would like you to know before we put NEW LENSES into your OWN (PREVIOUSLY WORN) EYEGLASS FRAMES. 1. Although we use the utmost care when manufacturing and inserting lenses into our patients' own (previously worn) frames, an older frame will occasionally break in the process. Plastic materials become brittle, and solder points on metal frames can weaken with wear over time. 2. Therefore, we and our outsourced optical laboratory cannot be held responsible if breakage occurs during the process of putting NEW lenses in your OWN eyeglass frames. 3. Frame manufacturers regularly discontinue old frame styles as they launch new ones. Because of this, we may have difficulty obtaining replacement parts for your own frame if it breaks in the future. 4. Your prescription lenses are an investment in your vision. Because of this, we highly recommend that you order them to be placed in a new, high-quality frame. 5. If you choose to have us make your new lenses for your own frame, and it breaks during the process, you will be responsible for (A) the purchase price of a new eyeglass frame and (B) another set of ophthalmic lenses to be cut and fit into that new frame.

Due to the custom nature of glasses, all Prescription Frame and Sunglass Sales are Final: No refunds or exchanges will be given. Payment is expected at time professional services are rendered and no refunds will be made for services or products.

In addition, I authorize Custom Eyesto charge my credit card for agreed upon purchases for phone orders. This online signature applies to any phone orders and I understand that there are no refunds.

We are not responsible for glasses or contacts that are not picked up within 90 days. Payments or deposits will NOT be refunded.

By signing my name below, I have read, and agree to all of the above policies.

Patient Signature: Date:

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