Privacy Practices Form

Please be sure to check every consent box and sign your name in all signature fields before submitting the form.

ACKNOWLEDGEMENT OF PRIVACY PRACTICES(Required)

I acknowledge that I have received/reviewed a copy of the Notice of Privacy Practices at this office location. I further consent to the release of my health information for the purpose of the treatment, payment, and health care operations and as authorized or required by law under the circumstances described in the Notice of Privacy.

Patient/Guardian* Signature(Required)

Date

MM slash DD slash YYYY

FOLLOW-UP EXAMINATION POLICY/INSURANCE(Required)

All eyeglasses and contact lens prescription checks must be completed within 30 days from the date of exam to avoid additional fees. Follow up visits not completed within the 30 days period may be subjected to additional fees. CONTACT LENSES PRESCRIPTION MUST BE FINALIZED WITHIN 30 DAYS.

Office visit fees will include the initial visit and one follow up examination if needed. Additional follow up visits may sometimes be required and will be subject to additional fees.

I understand I am responsible for all professional fees incurred during my visits(s) and that there is a NO REFUND policy on professional services. Additionally, I am authorizing Essential Eye Care & Optical to utilize my insurance and I agree to assume responsibility of full payment of any remaining balances not covered by the agreed third party.

Patient/Guardian* Signature(Required)

Date

MM slash DD slash YYYY

DILATION(Required)

I, named below, have been informed by my optometrist and/or office staff of the need for a dilated examination of my eyes. It has been explained to me and I understand that a condition with the potential for partial or total loss of vision may exist and without dilation may go undetected. Dilation is included in all initial comprehensive exam services. If the dilation is refused today, patient is advised they can return within 30 days from initial date of service to complete the dilated portion of exam.

(Dilation Refused) I understand I have 30 days to return and have that portion of the exam completed if I choose to.

Name(Required)

First Last

Patient/Guardian* Signature(Required)

Date

MM slash DD slash YYYY

How did you hear about us?

All eyeglasses and contact lens prescription checks must be completed within 30 days from the exam date. Due to the time involved and custom nature of eyeglasses, no cash refunds. Warranty and exchanges may apply.

Consent(Required)

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