1. My consent for medical treatment by the doctor/Avery Eye Clinic Staff and acknowledge no guarantees have been made regarding the results of treatment/exam.
2. Payment from my insurance company to Avery Eye Clinic for medical treatment.
3. I understand I am responsible for all charges not paid by my insurance.
4. The release of any medical records when necessary to/from another physician, hospital or other medical facility.
5. Release of medical information to/from the insurance for claims processing.
6. I AM RESPONSIBLE IF I DID NOT OBTAIN A REFERRAL OR AUTHORIZATION FROM MY INSURANCE COMPANY OR PRIMARY CARE PHYSICIAN.