Patient Registration Form

I authorize the release of medical and other information acquired in the course of my examination and/or treatment to the necessary insurance companies, third party payors, &/or health practitioners required to participate in my care. I authorize/ request my insurance company to make direct payment to Sage Creek eye centre . I understand that I am financially responsible for charges not covered by my insurance plan. *Accepted forms of payment: Cash, Visa, Mastercard, American Express, Interac.