Office Policy Form

Optometrist & Specialty Contact Lenses Professional located in Rancho Cucamonga, CA

Crystal Vision Optometry

*Patients must initial beside each statement to acknowledge the policy and then sign at the bottom of the page* 


In order to maintain economical profesional fees and material charges, the following office policy stands: 

A. When only professional fees are incurred, payment is expected at the time of service.


B. When professional fees and material charges are incurred, total payment is required before the order can be placed


C. When only material charges are incurred (glasses or contacts) total payment is required before the order can be placed.


D. All services and sales are FINAL. There are no refunds or exchanges.


E. We cannot be responsible for delays due to breakage and /or manufacturer back-ordered materials. Please note: We have no control over delays/loss

of items via the United States Postal Service (USPS), United Parcel Service (UPS), or other Carrier organizations


F. Any dissatisfaction with lenses/frames must be brought to our attention within 30 days of dispensing/delivery for valid/appropriate



G. In the unlikely event that your visual system cannot tolerate certain styles of multi-focal lenses (if needed):

1. Progressive lenses can be substituted with a pair of conventional trifocal or bifocal lenses at no additional cost to you.

2. Trifocal lenses can be substituted with a pair of conventional bifocal lenses at no additional cost.

3. Bifocal lenses can be substituted with a pair of single vision distance or near lenses at no additional cost.

4. Please note: No refunds will be made on the difference between multifocal style charges. Lens substitutions are comparable

for tints, coatings, etc. 


H. Written contact lens prescriptions are obtainable after completion of the fitting period for established fits only. The follow-up visit is included in the quoted cost for contact lens fitting. Contact lens fittings are performed strictly within 3 months from your eye exam and follow-up visits must be completed within 3 months of the fitting to avoid additional charges for re-fit and/or an additional eye exam. 


I. When using old frames for prescription lenses, neither we nor our optical laboratories can accept responsibility for frame damage in

the process of handling.


J. Frames/ spectacle lenses lose their ability to withstand the pressure of adjustments/repairs with time. While we use the utmost care,

we are not responsible for any damages incurred during the process.


K. Scratch resistant lens coatings are just that, resistant, and not scratch-proof


L. Orders that have not been dispensed/picked-up after 3 months from the first attempt of notice will be discarded, restocked, or donated
to charity


We accept most insurances and will do our best to pull the authorization and submit billing. Verification for eligibility of benefits is not a guarantee of payment. The undersigned authorizes direct payment to Dr. Adhikari, with any insurance benefits otherwise payable to the undersigned, for Dr. Adhikari’s services. It is the patient’s responsibility to pay for services and materials not covered by insurance.


A referral for further evaluation/treatment may be made when a potential problem exists that could have significant consequences if not appropriately addressed. While we use the utmost care, we cannot absolutely guarantee that all referral letters, phone calls, or faxes are received. We make the referral in good faith and with acknowledgement. In order to safeguard your wellbeing, it is incumbent upon you to contact us if you have not obtained your referral appointment in a timely fashion. The ultimate decision/responsibility to keep the appointment is always yours.


A return visit to our office to further evaluate, monitor, or treat a present condition is made in good faith. Without further follow-up visits, some conditions may have consequences that could lead to blindness or be a threat to your health. When appointments made for further check-ups are not kept, the responsibility for the condition becomes yours

Crystal Vision Optometry


I authorize the release of any medical or other information necessary to process this transaction. I also authorize any insurance benefits to be paid to Dr. Adhikari. I understand that if in the event my insurance carrier pays less than the actual bill for the services that have been provided to me. I agree to be responsible for payment of all services and/or materials rendered on my behalf and/or my dependent(s). I have read and understand the content of these two pages.


Please do not submit any Protected Health Information (PHI).

Rancho Cucamonga

11940 East Foothill Blvd, Suite 103
Rancho Cucamonga, CA 91739

Hours Of Operation:

Monday:         9:00 AM - 5:30 PM
Tuesday:        Varies
Wednesday:   9:00 AM - 5:30 PM
Thursday:       9:00 AM - 4:30 PM
Friday:            9:00 AM - 5:30 PM
Saturday:       Closed
Sunday:         Closed