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ACKNOWLEDGMENT OF OFFICE POLICIES & FINANCIAL RESPONSIBILITY NOTICE

RELEASE FORM FOR USING PATIENT’S OWN EYEGLASS FRAMES

AUTHORIZATION TO RELEASE PROTECTED HEALTH INFORMATION

MINOR CONSENT FORM

CONSENT TO RELEASE PROTECTED HEALTH INFORMATION TO SPECIFIC INDIVIDUALS

REFRACTION FEE NOTICE

NOTICE OF CONTACT LENS FITTING FEES

ACKNOWLEDGEMENT OF RECEIPT NOTICE OF PRIVACY PRACTICES

AUTHORIZATION & CONSENT TO TREAT

EYEGLASS LENS MATERIAL DUTY TO WARN/PATIENT REJECTION AND WAIVER FORM

Contact Info



2596 Reynolda Rd Suite A
Winston-Salem, NC 27106

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336-777-1722



336-725-6954



support@idealeyesnc.com

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Mon-Thu: 9am – 5pm
Friday: 9am – 12pm
Sat, Sun: Closed
(Closed for lunch daily from 12-1pm)

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