I authorize the Center for Vision & Learning to charge my credit card for optometric services. My card information will be entered into and stored by a secure card service.

I understand that charges will first be submitted to my insurance, when applicable, and any remaining charges will then be forwarded to me as a bill for 60 days. During this time period, I will have the opportunity to contact the office with any questions regarding my statement. I understand that no charges will be made until a bill has been sent home for review.

In the event that an outstanding balance remains 60 days past the date of service, I will receive a phone call letting me know when my credit card will be charged. If no response is received from me before the deadline, by credit card will be charged for the outstanding balance.