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Eyes For Wellness

9302 N. Meridian Street, Suite 170

Indianapolis, IN 46260

317-818-0541

317-818-1756

Adult Patient History Questionnaire

The undersigned agrees that all past due amounts shall be charged $10.00 peer month on the unpaid balance commencing thirty (30) days after billing. The undersigned assumes and agrees to pay all collection agency fees paid by us, attorney fees, court costs, and other cost incurred while collecting the amount due.

The under signed give permission to and exchange information to those professionals that they are being referred to or to those professionals that referred them to our office. The undersigned gives permission to exchange information with their insurance company when necessary.

Eyes For Wellness * 9302 N Meridian St, Suite 170 * Indianaoplis, IN 46260 * 317-818-0541 * 317-818-1756 fax * www.eyes4wellness.com *

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Location

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Hours of Operation

Our Regular Schedule

Monday:

9:30 am-6:30 pm

Tuesday:

9:30 am-6:30 pm

Wednesday:

9:30 am-6:30 pm

Thursday:

9:30 am-6:30 pm

Friday:

Closed

Saturday:

Closed

Sunday:

Closed