Covid Screening and Protocol Acknowledgement

Financial Agreement Form

Consent for Electronic Delivery of Prescriptions

Dr. Kurtbay Optometry

750 Irving Street

San Francisco, CA 94122

(Phone) 415-759-5448

(Fax) 415-759-9399 

1. All places of contact (equipment, tools, pens, chairs, tables) are disinfected between each patient visit.
2. All interactions will be as touchless as possible.
3. All frames, including frames brought for adjustment, are washed with a disinfectant solution and soap.
4. Restrooms are currently unavailable due to higher transmission risk.
5. Masks are only required during the exams/follow ups. **Masks are no longer required in the front office for cases such as pick ups or frame selections. ** 
6. By signing this document, I understand Dr. Kurtbay Optometry is taking measures to mitigate the risks of infection and will not hold my doctor or office staff responsible if I contract Covid-19 or any other virus.

Please answer the questions below 

Financial and Insurance Policy Consent and Disclosure

I have read, understood, and agree to authorize "Dr. Kurtbay Optometry" to submit and sign insurance claims on my behalf. I also authorize the release of any information pertinent to my insurance company or their agents. I understand that this authorization is a direct assignment of my rights and benefits under my policy and that the payments will be paid directly to "Dr. Kurtbay Optometry." I agree to be responsible for all fees not covered by my vision insurance or should my insurance company deny payment to Dr. Kurtbay Optometry.

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Consent for Electronic Delivery of Prescriptions

I acknowledge that my prescription for glasses and/or contact lenses will be sent to me via email.