Enroll in the Family Vision Plan

Family Vision Plan Enrollment Form:

Name
First Last
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone
Email*
Select a Plan*
We have two plans: Up to 3-Person Plan, and 4 or More Plan
- No other insurances or discounts of any type can be used in conjunction with the Family Vision Plan
- If member has other insurances, the Family Vision Plan can be used for additional care and services not covered by other insurances.
- Plan covers the individual who has enrolled, his or her spouse, and his or her children or the children whom they are legal guardian of.
- Plan may be used as often as required throughout the coverage period
- Published discounts may be changed without notice

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Agreement to Terms and Conditions*
- I Agree
By checking this box, I agree to the terms and conditions of the Family Vision Plan;
I understand that when i visit the office, my chosen fee will be applied to that bill, and will be due in full at the time of my next/first visit.
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