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If the patient is 18 years of age or younger, this form needs to be filled out IN ADDITION to the Patient and Health Forms.

Cancellation Policy

It is our goal to be able to serve all of our patients in a timely manner. Appointments are in high demand, and your early cancellation will allow other patients access to timely eye care.

Late Cancellations & No Show Policy
A late cancellation is when a patient fails to cancel their scheduled appointment with a 24-hour advance notice and will be be considered a missed appointment.

Failure to be present at the time of a scheduled appointment will be recorded in your chart as a "no show".

-First missed appointment: There will be no charge, but the "no show" will be recorded in your chart.

-Second missed appointment: A $20 fee will be billed to your account and must be paid prior to scheduling future appointments.

-Third missed appointment: A $50 fee will be billed to your account and you may be discharged from the practice.

We are proud to serve patients from Beavercreek, Centerville, Dayton, Fairborn, Jamestown, Huber Heights, Kettering, Lebanon, Moraine, Oakwood, Vandalia, West Carrolton, Xenia, Yellow Springs and other surrounding communities.