I have read and answered the above questions to the best of my knowledge. I authorize Vision Source to release information as to exam, diagnosis or treatment rendered to me or my child to third party payers and/or health practitioners. I will be responsible for all charges that are not covered or paid by my policy. I am aware that the contact lens fitting and follow-up care may not be covered under the "exam" definition in my policy. I understand that my prescription will be given to vendors in order for Vision Source to be able to process my materials. I further understand that payment is due at the services are rendered unless prior arrangements are made.