Refraction Form

Refraction Consent
I agree to have this service performed and am aware that it may be left to my responsibility by my insurance company.
As part of your regular scheduled medical eye exam today, the doctor or other clinical staff, may perform a refraction on you. A refraction is the part of the exam where the phoropter is placed up against your eyes and the lenses are flipped while asking the questions "better 1" or "better 2". This is how the doctor and clinical staff determine your best-corrected vision and your glasses prescription.

The charge for the refraction is $45.00, and most insurance companies do not pay for this service, and it may be deemed your responsibility by your insurance company.

By signing below, you are agreeing to have this service performed and are aware that it may be left to your responsibility by your insurance company.
Signature of Patient or Guardian
First Last
Date
Date Format: MM slash DD slash YYYY
Foregoing the Refraction
I understand that foregoing the refraction exam means I will not be provided with a glasses prescription.
...If you are not agreeing to the $45.00 charge for the refraction and would not like this performed during your exam, please sign below. Without this exam we can't
provide a glasses prescription. A return appointment would be necessary to acquire your prescription.*
Signature of Patient or Guardian
First Last
Date
Date Format: MM slash DD slash YYYY
Comments
This field is for validation purposes and should be left unchanged.

Nashville

Franklin