YOUR OCULAR HISTORY (Have you been diagnosed with any of the following in the past?)
Family History (Has anyone in your family (blood relative) had any of the following? )
WE APPRECIATE THE OPPORTUNITY OF SERVING YOU. WE PLEDGE TO GIVE YOU OUR VERY BEST MEDICAL CARE.
Insurance provides for your reimbursement on allowed medical charges. As a courtesy to you, we will provide an
itemized statement that you may send to your insurance company for payment. We will be happy to submit to most
insurance carriers if you have provided us with policy numbers, address, place of employment and any other pertinent
information. You are responsible for all deductibles and charges not covered by insurance. Please understand that we
cannot, as a third party, become involved in prolonged insurance negotiations: this is your responsibility.
I authorize the release of any medical information necessary to process any claim. I permit a copy of the authorization
to be used in place of the original. This authorization may be revoked by either me or my insurance company at any
time in writing.
AUTHORIZATION FOR RELEASE OF MEDICAL RECORDS:
I authorize the Doctor to release any medical information including diagnosis, x-rays, test results, reports and records
pertaining to any treatment or examination rendered to me. I understand that this medical information may be used for
any of the following procedures: diagnostic, insurance, legal, scientific research, publications, presentations, and at times when the Doctor deems it necessary in
order to ensure the best medical care on my behalf. I further understand that any person(s) that receive these medical
records will not release any of the medical information obtained by this authorization to any person or organization
without further authorization signed by me for release of the information.
TERMS AND CONDITIONS
Customer agrees to pay a finance charge of one and one-half percent (1 ½%) per month on all amounts due and owing
to Hoopes Vision Correction Center, EyeSurg of Utah or Laser and Refractive Surgery Center of Utah.
ATTORNEY’S FEES AND COSTS:
If any legal action is necessary to enforce the terms of this Agreement, or if it is necessary to employ the services of
an attorney to enforce the terms of this Agreement, the party in default or in breach hereof agrees to pay the other
party’s reasonable attorney’s fees and court costs in addition to any other relief to which it may be entitled if
Customer fails to pay any amounts owing hereunder when due, or otherwise breaches any terms of this Agreement.
Customer agrees to pay up to a 40% collection expense incurred by Hoopes Vision Correction Center in attempting to
collect such amounts from Customer, in addition to the aforementioned attorney’s fees and cost
IN CASE OF EMERGENCY PLEASE CONTACT: