Your Journey to Better Vision Starts Here!

Scheduling a FREE, no obligation consultation appointment is a great opportunity to meet your surgeon, ask any questions you have, and find out if you are a good candidate for LASIK.

Assignment of Benefits

  • Assignment of Benefits/Authorization

    I hereby assign payment directly to Carolina Ophthalmology of the surgical and/or major medical benefits, if any, otherwise payable to me for the professional services rendered in the course of any examination or treatment. This authorization shall remain valid until revoked in writing.

  • Responsibility for Payment of Medical Services

    I understand that Carolina Ophthalmology will file my insurance as a courtesy. However, I am ultimately responsible for all medical fees relating to my care. Should my insurance deny for any such reasons as; an authorization, deductable, or non-covered service, I understand that I will be responsible for my bill.

  • Notice of Privacy Practices

    I understand that Carolina Ophthalmology’s Notice of Privacy Practices informs me how my medical information may be used pertaining to treatment, payment and healthcare operations. By submitting this form it signifies that I have read or printed a copy of this notice.

  • In order to better serve our patients, their families, and comply with the federal government’s privacy act, we ask that you list below who you give Carolina Ophthalmology permission to discuss your medical information with:

  • By submitting this form, I certify that I have the legal authority to execute this document and that this submission constitutes a legal signature authorizing all of the sections contained on this form.

“During a free consultation, Pam explained everything they were going to do. The initial tests, the procedure, the cost and financing options were all explained. The upcoming year I set aside money in my medical savings account so I could go forward with the procedure. The actual LASIK process takes literally seconds per eye to complete. I sat up and could see without glasses or contacts immediately!”

Laura A. Hite, RN, BSN, CDE

See what you’ve been missing!

Stop struggling with your eyesight! Now is the time to schedule your free LASIK consultation with Dr. Bryan and Dr. Shaw at Carolina Ophthalmology and find out if you’re a candidate for laser vision correction. Why not take our Self Evaluation Test to get started?