Please download the PDF file, print, and fill out the form BEFORE the appointment to increase efficiency. Forms are also provided at the time of visit.
New Patient Form
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Established Patient Form
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Information
Golden Eyes Exam - digital wellness examination
Notices of Privacy Practices
New Patient Form
CLICK HERE to download paperwork
Established Patient Form
CLICK HERE to download paperwork
Information
Golden Eyes Exam - digital wellness examination
Notices of Privacy Practices
Office Policy
Welcome to our office! We thank you for selecting us to serve your vision needs. Our Staff is a professional team dedicated to providing the highest quality eye health care to our patients.
So that we might all enjoy a smooth working relationship, we ask you to take a couple of minutes to read over our basic office policies. If you have questions, we will be happy to answer them for you.
Thank you, and once again, welcome!
So that we might all enjoy a smooth working relationship, we ask you to take a couple of minutes to read over our basic office policies. If you have questions, we will be happy to answer them for you.
Thank you, and once again, welcome!
Patient Information
All patients, or their agents, must complete our “Patient Information” form before receiving any service. It is your responsibility to keep the office informed of any changes in information. (i.e. address, phone number, insurance, etc.) Pt medical records will be maintained for 5 years from the last date of service. Minor’s records will be maintained for 5 years after the age of 18.
Appointments
We strive to keep your waiting time to a minimum; we recognize that your time is as valuable as is the doctors’. Therefore, we request a 24-hour notice if you find it necessary to cancel your appointment. As emergencies do arise, we ask your patience if there is a delay during your appointment time due to a patient in need of immediate care. Be assured that we will provide you with the same high-quality care.
$40 fee applies to any patient that does not show or fails to give us any *advanced notice. To schedule any future appointments with us, a $40 fee will be collected (payment collected over phone).
Payment Information
Payment for professional services is due at the time of service. Full payment of the total charges is required on all glasses and contact lenses when the order is placed. For your convenience, we accept cash, debit, VISA, MasterCard, Discover, American Express, and Apple Pay. Sorry, no personal checks.
Rx Guarantee
If your new prescription does not meet your vision needs, contact us within 60 days from that date of your initial visit so that we can make the proper prescription adjustments. Additional fees apply after 60 days.
Return Policy for Eyewear & Contact Lenses
Eyeglasses are custom-made for you based on your unique prescription and measurements that vary based on frame. Because it is designed for you only, there are no refunds on any purchased eyewear (including lenses & frames). Lens orders are started as soon as possible to ensure quick turn-around time. Once the lab starts making your lenses, we are unable to cancel the order. Since we are unable to resell glasses once they are made, any returns for exchange are subject to a 20% restocking fee. When vision insurance is used, restyling for a new frame is prohibited. There may be occasional issues with eyeglasses that are not the fault of the patient; in which case our office will take action to fix these problems at no cost. This includes: prescription adjustments and changes, non-adaptation to prescriptions, lenses, and materials, lens defects, lab errors, and other unique issues on a case-by-case basis. If there is a need for the prescription to be adjusted, such changes are included at no charge for a one-time redo within 60 days from of your eye examination. Additional lens remakes are charged at 50% of the original order price, which does not include insurance benefit.
We understand that some patients require time to adapt to progressive lenses. If you have difficulty with the lenses, we can offer you to replace the progressive lenses to a line bifocal or single vision lenses within 60 days of the dispensing date. There are no refunds of the difference in costs if the remade pair is of lesser value.
All sales that are non-prescription sunglasses are final and non-refundable. Patients have 14 days from the date of purchase to exchange a sunglass frame at equal or lesser value; the patient is responsible for the difference of the higher value sunglass frame and subject to a 20% restocking fee. Exchanged frames must be in a re-sellable condition with no damage or scratching.
Stock lenses that are made in-house do not have warranty. If you are in need of new lenses due to defects and scratches from normal wear within 1 year from receiving the glasses, then new lenses can be purchased at 50% of your purchase price of the lens.
If you received free polycarbonate single vision lenses with your frame purchase, then there is no warranty on the lenses. If you are in need of new lenses for that frame, then it can be purchased at a discounted rate of $50.
With regard to the sale of non-specialty soft contacts lenses, any non-expired, unopened & unmarked boxes may be returned for credit, within 60 days if there has been a change to your prescription. Any changes are subject to a 20% restocking fee. All sales of specialty gas permeable (i.e., RGP) and hybrid (i.e., containing both rigid and soft components) contact lenses are final. During the trial period in determining the proper prescription for such specialty lenses, any exchanges or returns will be granted at no charge so long as enough time is given for the lenses to be mailed back to the manufacturer, in order to meet the manufacturer’s 90-day exchange/return policy.
Frame and Lens Warranty
As long as the frame is not discontinued, your new frame has a 1-year, 1-time, manufacturer’s warranty or better, depending on the frame manufacture (final review is under manufacture discretion). If your frame breaks under normal wearing conditions, we will repair or replace it at no charge. Lenses purchased with Hoya Super HiVision EX3 or Recharge have a 2-year unlimited warranty against scratches. Crizal Sapphire and Prevencia products have a 2-year, 2-time replacement warranty against scratches. If vision insurance was used with your purchase, then the warranty applies based on your specific vision plan. Every insurance company policy on warranties vary, and we can assist you with that. Otherwise, contact your insurance company for specific information if you want to do your own research. There is no warranty on lost items.
Even though the eyeglass frame or lenses is under warranty by the manufacturer or optical lab, they do not pay for the shipping and handling for the exchange of the defective frame/lenses for the new frame/lenses. The patient will be responsible for the two-way shipping costs involved ($20.00 for frame. $10.00 for lenses)
Picking Up Eyeglasses & Contact Lenses
All eyeglasses and contact lenses that have been prescribed, fitted, and purchased by the patient will be kept in the office for a total of 6 months from the date of purchase. If the patient does not pick up his/her eyeglasses or contact lenses within 6 months, we will subsequently donate them to charity. We are not responsible for glasses/contacts not pick-up within 6 months.
Request for Medical Records/Forms
Patients requesting their medical records will be charged $0.60/page. Expired prescriptions are never printed because they cannot be filled. Glasses and contact lens information can be found in the patient’s medical records. Special testing records cannot be printed. Only a digital copy is available to maintain quality. A copy of special testing record is $5.00/page. Doctors/Attorneys requesting an affidavit, copies of a patient’s medical records, and postage will be subject to a fee of $50. We shall furnish the records to the patient within 30 days after the date of receipt of the request. Any form, at your request, to be filled out by the doctor are subject to a $25 fee/form.
Insurance
We file insurance claims as a courtesy to our patients. Your insurance is a contract between you and your insurance company. Your account with this office is your responsibility whether or not your insurance company pays. We will help you receive the maximum benefit from your insurance company. However, if your insurance company has not paid your account in full within 60 days, your account will become a “CASH” account with the balance due and payable by you within 30 days.
Please be aware that some, and perhaps all, medical services provided may be non-covered services and not considered reasonable and necessary under some insurance plans. All fees for non-covered services, co-pays, deductibles, and overages are due at the time of service.
Social Security Number
It is a policy and requirement for this office to obtain a social security number for any patient, parents or individual responsible for the child(ren). If you do not wish to provide us with your social security number, you will need to pay for the visit and will be reimbursed once your insurance company pays the claim.
Unresolved Accounts
Finance charges of 1 ½ % per month (18% per annum) will be assessed to any unpaid balance. If we find it necessary that an account be forwarded to a collection agency or an attorney, a fee of 33% of the charges owed will be added to the total amount due and accruing interest. Any checks returned to us unpaid by the banking institution will be assessed a $25.00 fee. Deposits are not refundable.
Minors
For any patients who are minors, the parent(s) or guardian(s) are responsible for full payment and will receive the billing statements for any minors receiving services. A signed release to treat may be required for unaccompanied minors.
Contact Lens Fitting and Evaluation:
Contact lenses are classified as medical devices by the FDA. They are not considered over-the-counter (OTC) devices. This means that contact lens wears is under the supervision of an eye doctor and that that doctor has to evaluate and re-evaluate the fir of your contacts every year in order to determine the correct prescription for your eyes.
Contact Lens Prescription Expiration: One year
Contact lens prescriptions expire in one (1) year in most cases. It is rare that contact lenses prescriptions are written for longer than 1 year. Contact lens prescriptions can be filled within this period as long as it does not exceed one year’s worth of wear. Although contact lens modalities can range from one-day to one-month, the reason behind its shorter duration is because a contact lens is in direct contact with your eye. The interaction may change on a microscopic level over time that can lead to ocular health problems.
Back-up Glasses:
It is important that the patient has a back-up pair of glasses when also using contact lenses. The eyes need a break from contact lens wear. It is recommended that the eyes have a few hours a day without contact lenses on the eyes. More importantly, there will be days where the eyes cannot tolerate contact lens wear and wearing glasses will be the only option to see. Such events include but not limited to: eye infections, allergies, no contact lenses left, and ripped contact lenses.
Finalization of Contact Lens Prescription:
After the eye doctor has written a final prescription, it is expected that the patient will purchase retail boxes for everyday wear. The diagnostic/trial contact lens is not meant to last the entire year. The diagnostic/trial contact lens last depending on the modality of wear. Usually a soft contact lens will either last for 1-day, 2-weeks, or 1-month.
Torn or Lost Contact Lenses:
We do not warranty lenses against loss or damage. In some cases, we can supply a replacement soft lens from our diagnostic fitting set. Modern soft contact lenses are very durable and rarely tear. If tearing or damage is a consistent issue, a review of handling and cleaning procedures should be evaluated to help prevent future problems. Diagnostic lenses are not available for gas permeable prescriptions.
Our Contact Lens Guarantee:
The health of your eyes and your satisfaction are very important to us. If we are unable to fit you with contact lenses, we will apply your contact lens fitting and evaluation fee to the purchase of glasses in our optical department.
For patients that purchased boxes of contact lenses from us, you may return one box, per eye of open contact lenses and all factory sealed contact lens boxes within thirty (30) days of purchase for credit towards the purchases of glasses in our optical department.
When you purchase an annual supply of contact lenses from us, we will exchange any defective lenses and supply you with an emergency pair, if needed
GEO Standard of Care:
Our philosophy is preventative care. FDT visual field screening is important in the routine eye exam because it can help detect early signs of glaucoma, stroke, brain tumors, macular degeneration, diabetes, high blood pressure and other neurological problems. It can also help monitor changes caused by some medication. This is a non-covered fee of $10. If abnormal, then a more detailed visual field may be requested.
All patients, or their agents, must complete our “Patient Information” form before receiving any service. It is your responsibility to keep the office informed of any changes in information. (i.e. address, phone number, insurance, etc.) Pt medical records will be maintained for 5 years from the last date of service. Minor’s records will be maintained for 5 years after the age of 18.
Appointments
We strive to keep your waiting time to a minimum; we recognize that your time is as valuable as is the doctors’. Therefore, we request a 24-hour notice if you find it necessary to cancel your appointment. As emergencies do arise, we ask your patience if there is a delay during your appointment time due to a patient in need of immediate care. Be assured that we will provide you with the same high-quality care.
$40 fee applies to any patient that does not show or fails to give us any *advanced notice. To schedule any future appointments with us, a $40 fee will be collected (payment collected over phone).
Payment Information
Payment for professional services is due at the time of service. Full payment of the total charges is required on all glasses and contact lenses when the order is placed. For your convenience, we accept cash, debit, VISA, MasterCard, Discover, American Express, and Apple Pay. Sorry, no personal checks.
Rx Guarantee
If your new prescription does not meet your vision needs, contact us within 60 days from that date of your initial visit so that we can make the proper prescription adjustments. Additional fees apply after 60 days.
Return Policy for Eyewear & Contact Lenses
Eyeglasses are custom-made for you based on your unique prescription and measurements that vary based on frame. Because it is designed for you only, there are no refunds on any purchased eyewear (including lenses & frames). Lens orders are started as soon as possible to ensure quick turn-around time. Once the lab starts making your lenses, we are unable to cancel the order. Since we are unable to resell glasses once they are made, any returns for exchange are subject to a 20% restocking fee. When vision insurance is used, restyling for a new frame is prohibited. There may be occasional issues with eyeglasses that are not the fault of the patient; in which case our office will take action to fix these problems at no cost. This includes: prescription adjustments and changes, non-adaptation to prescriptions, lenses, and materials, lens defects, lab errors, and other unique issues on a case-by-case basis. If there is a need for the prescription to be adjusted, such changes are included at no charge for a one-time redo within 60 days from of your eye examination. Additional lens remakes are charged at 50% of the original order price, which does not include insurance benefit.
We understand that some patients require time to adapt to progressive lenses. If you have difficulty with the lenses, we can offer you to replace the progressive lenses to a line bifocal or single vision lenses within 60 days of the dispensing date. There are no refunds of the difference in costs if the remade pair is of lesser value.
All sales that are non-prescription sunglasses are final and non-refundable. Patients have 14 days from the date of purchase to exchange a sunglass frame at equal or lesser value; the patient is responsible for the difference of the higher value sunglass frame and subject to a 20% restocking fee. Exchanged frames must be in a re-sellable condition with no damage or scratching.
Stock lenses that are made in-house do not have warranty. If you are in need of new lenses due to defects and scratches from normal wear within 1 year from receiving the glasses, then new lenses can be purchased at 50% of your purchase price of the lens.
If you received free polycarbonate single vision lenses with your frame purchase, then there is no warranty on the lenses. If you are in need of new lenses for that frame, then it can be purchased at a discounted rate of $50.
With regard to the sale of non-specialty soft contacts lenses, any non-expired, unopened & unmarked boxes may be returned for credit, within 60 days if there has been a change to your prescription. Any changes are subject to a 20% restocking fee. All sales of specialty gas permeable (i.e., RGP) and hybrid (i.e., containing both rigid and soft components) contact lenses are final. During the trial period in determining the proper prescription for such specialty lenses, any exchanges or returns will be granted at no charge so long as enough time is given for the lenses to be mailed back to the manufacturer, in order to meet the manufacturer’s 90-day exchange/return policy.
Frame and Lens Warranty
As long as the frame is not discontinued, your new frame has a 1-year, 1-time, manufacturer’s warranty or better, depending on the frame manufacture (final review is under manufacture discretion). If your frame breaks under normal wearing conditions, we will repair or replace it at no charge. Lenses purchased with Hoya Super HiVision EX3 or Recharge have a 2-year unlimited warranty against scratches. Crizal Sapphire and Prevencia products have a 2-year, 2-time replacement warranty against scratches. If vision insurance was used with your purchase, then the warranty applies based on your specific vision plan. Every insurance company policy on warranties vary, and we can assist you with that. Otherwise, contact your insurance company for specific information if you want to do your own research. There is no warranty on lost items.
Even though the eyeglass frame or lenses is under warranty by the manufacturer or optical lab, they do not pay for the shipping and handling for the exchange of the defective frame/lenses for the new frame/lenses. The patient will be responsible for the two-way shipping costs involved ($20.00 for frame. $10.00 for lenses)
Picking Up Eyeglasses & Contact Lenses
All eyeglasses and contact lenses that have been prescribed, fitted, and purchased by the patient will be kept in the office for a total of 6 months from the date of purchase. If the patient does not pick up his/her eyeglasses or contact lenses within 6 months, we will subsequently donate them to charity. We are not responsible for glasses/contacts not pick-up within 6 months.
Request for Medical Records/Forms
Patients requesting their medical records will be charged $0.60/page. Expired prescriptions are never printed because they cannot be filled. Glasses and contact lens information can be found in the patient’s medical records. Special testing records cannot be printed. Only a digital copy is available to maintain quality. A copy of special testing record is $5.00/page. Doctors/Attorneys requesting an affidavit, copies of a patient’s medical records, and postage will be subject to a fee of $50. We shall furnish the records to the patient within 30 days after the date of receipt of the request. Any form, at your request, to be filled out by the doctor are subject to a $25 fee/form.
Insurance
We file insurance claims as a courtesy to our patients. Your insurance is a contract between you and your insurance company. Your account with this office is your responsibility whether or not your insurance company pays. We will help you receive the maximum benefit from your insurance company. However, if your insurance company has not paid your account in full within 60 days, your account will become a “CASH” account with the balance due and payable by you within 30 days.
Please be aware that some, and perhaps all, medical services provided may be non-covered services and not considered reasonable and necessary under some insurance plans. All fees for non-covered services, co-pays, deductibles, and overages are due at the time of service.
Social Security Number
It is a policy and requirement for this office to obtain a social security number for any patient, parents or individual responsible for the child(ren). If you do not wish to provide us with your social security number, you will need to pay for the visit and will be reimbursed once your insurance company pays the claim.
Unresolved Accounts
Finance charges of 1 ½ % per month (18% per annum) will be assessed to any unpaid balance. If we find it necessary that an account be forwarded to a collection agency or an attorney, a fee of 33% of the charges owed will be added to the total amount due and accruing interest. Any checks returned to us unpaid by the banking institution will be assessed a $25.00 fee. Deposits are not refundable.
Minors
For any patients who are minors, the parent(s) or guardian(s) are responsible for full payment and will receive the billing statements for any minors receiving services. A signed release to treat may be required for unaccompanied minors.
Contact Lens Fitting and Evaluation:
Contact lenses are classified as medical devices by the FDA. They are not considered over-the-counter (OTC) devices. This means that contact lens wears is under the supervision of an eye doctor and that that doctor has to evaluate and re-evaluate the fir of your contacts every year in order to determine the correct prescription for your eyes.
Contact Lens Prescription Expiration: One year
Contact lens prescriptions expire in one (1) year in most cases. It is rare that contact lenses prescriptions are written for longer than 1 year. Contact lens prescriptions can be filled within this period as long as it does not exceed one year’s worth of wear. Although contact lens modalities can range from one-day to one-month, the reason behind its shorter duration is because a contact lens is in direct contact with your eye. The interaction may change on a microscopic level over time that can lead to ocular health problems.
Back-up Glasses:
It is important that the patient has a back-up pair of glasses when also using contact lenses. The eyes need a break from contact lens wear. It is recommended that the eyes have a few hours a day without contact lenses on the eyes. More importantly, there will be days where the eyes cannot tolerate contact lens wear and wearing glasses will be the only option to see. Such events include but not limited to: eye infections, allergies, no contact lenses left, and ripped contact lenses.
Finalization of Contact Lens Prescription:
After the eye doctor has written a final prescription, it is expected that the patient will purchase retail boxes for everyday wear. The diagnostic/trial contact lens is not meant to last the entire year. The diagnostic/trial contact lens last depending on the modality of wear. Usually a soft contact lens will either last for 1-day, 2-weeks, or 1-month.
Torn or Lost Contact Lenses:
We do not warranty lenses against loss or damage. In some cases, we can supply a replacement soft lens from our diagnostic fitting set. Modern soft contact lenses are very durable and rarely tear. If tearing or damage is a consistent issue, a review of handling and cleaning procedures should be evaluated to help prevent future problems. Diagnostic lenses are not available for gas permeable prescriptions.
Our Contact Lens Guarantee:
The health of your eyes and your satisfaction are very important to us. If we are unable to fit you with contact lenses, we will apply your contact lens fitting and evaluation fee to the purchase of glasses in our optical department.
For patients that purchased boxes of contact lenses from us, you may return one box, per eye of open contact lenses and all factory sealed contact lens boxes within thirty (30) days of purchase for credit towards the purchases of glasses in our optical department.
When you purchase an annual supply of contact lenses from us, we will exchange any defective lenses and supply you with an emergency pair, if needed
GEO Standard of Care:
Our philosophy is preventative care. FDT visual field screening is important in the routine eye exam because it can help detect early signs of glaucoma, stroke, brain tumors, macular degeneration, diabetes, high blood pressure and other neurological problems. It can also help monitor changes caused by some medication. This is a non-covered fee of $10. If abnormal, then a more detailed visual field may be requested.
Eyeglasses Purchased Elsewhere
You have a right to your eyeglass prescription, and as a patient at Golden Eyes Optometry, you will always be provided with a copy. We hope you will want to purchase your eyeglasses from us, because we believe we offer the best value when considering service, quality, and price. If you decide to shop elsewhere for eyeglasses, we certainly understand, and we will still be pleased to provide you with exceptional eye and vision care.
Local opticians generally do a good job in filling our prescriptions, but we have some concern with the use of eyeglass vendors over the internet. Fitting eyeglasses properly involves precise measurements, unbiased advice based on your individual needs, and skillful adjustments of the frame and lenses. Since internet vendors do not actually meet with you in person, they cannot provide those services. We provide all optical services at NO additional cost for patients who buy eyeglasses from us, but we cannot provide them for eyeglasses purchased elsewhere.
To avoid confusion and disappointment with glasses purchased elsewhere, here is a list of services we provide, along with those that we do not. Please check with the eyeglass vendor to determine return and refund policies in the event problems occur.
We provide the following service for eyeglasses purchased outside of our office:
The following services or measurements are NOT available if you purchase your eyeglasses elsewhere. These measurements should be provided by the optician fitting the glasses or the retailer making your glasses:
Local opticians generally do a good job in filling our prescriptions, but we have some concern with the use of eyeglass vendors over the internet. Fitting eyeglasses properly involves precise measurements, unbiased advice based on your individual needs, and skillful adjustments of the frame and lenses. Since internet vendors do not actually meet with you in person, they cannot provide those services. We provide all optical services at NO additional cost for patients who buy eyeglasses from us, but we cannot provide them for eyeglasses purchased elsewhere.
To avoid confusion and disappointment with glasses purchased elsewhere, here is a list of services we provide, along with those that we do not. Please check with the eyeglass vendor to determine return and refund policies in the event problems occur.
We provide the following service for eyeglasses purchased outside of our office:
- Prescription Verification: We will verify the basic lens parameters of the new eyeglasses to see if it matches our intended prescription, as well as recheck the refraction test to confirm that the prescription is correct, if necessary. This will be done at no charge within sixty (60) days of that date of the initial examination. We will not troubleshoot optical measurements taken by others. Visual problems may result if a correct prescription is made with inaccurate optical measurements. Correction or changes in the eyeglasses will foley be up to you and the eyeglass seller.
The following services or measurements are NOT available if you purchase your eyeglasses elsewhere. These measurements should be provided by the optician fitting the glasses or the retailer making your glasses:
- Pupillary Distance (PD) - Measurement of the distance between your eyes
- Segment Height
- Vertical Optical Center
- Custom Measurements for Position of Wear (POW)
- Eye Size
- Bridge Size
- Temple Length
- Frame Model & Color
- Lens Material & Index
- Multifocal Design & Brand
- Optional Lens Features - Such as tints, coatings, etc.
- Education & Training on Lens & Frame Features & Care
- Ongoing Frame Adjustments: We cannot be liable for the rare possibility of breakage
- Minor Repairs - We cannot be liable for the rare possibility of breakage