Patient Information
Name:
Optician:
Office:Insight Eyecare
Pair #1 - Detailed Breakdown
Insurance Plan:Self Pay
Pair #1 Subtotal:$0.00
TOTAL PATIENT PAYS: $0.00
TERMS AND CONDITIONS - PLEASE READ CAREFULLY
- Custom Lens Policy: Lenses are custom-made using each individual patient's chosen frame, facial size, and prescription. Any changes to the selected frame or lens options after your custom lenses are already made will be subject to a lens remake fee and/or a minimum 50% lens restocking fee. All glasses sales are final. No refunds will be issued for glasses (including prescription sunglasses) purchased through Insight Eyecare and Optical.
- Prescription Change Policy: Glasses remade due to a change in prescription within 60 days of eye exam will not be subject to additional charges*, provided the original prescription was determined by Insight Eyecare and Optical. Additional charges will apply for prescription changes after 60 days of exam.
- Insurance Processing Time: Eyeglasses (or prescription sunglasses) purchased with insurance are made at the vision plan provider's optical lab. Vision plan lab orders take a minimum of 10-14 business days to be processed.
- Patient-Supplied Frames: Patients may reuse an existing glasses frame at their own risk. Patients reusing their old glasses frame are responsible for all frame replacement costs and any lens remake costs in the event of loss and/or breakage of their frame. Neither our company nor a patient's insurance provider are responsible for a patient-supplied frame.
Patient Acknowledgment
I have read and agree to the terms and conditions stated above.
Patient SignatureDate: 12/19/2025