Prescription & Receipt Delivery Consent

Prescription & Receipt Delivery Consent
Prescription

I consent to receive my eyeglass and/or contact lens prescription(s) electronically.

Receipt

I consent to receive my receipt(s) electronically.

Electronic Communications Acknowledgement

If you request to receive any prescription(s) or receipt(s) via email or text, you understand that standard email and text messages are not considered HIPAA compliant methods of transmitting Protected Health Information (PHI). We can provide information by other alternatives including secure patient portal, postal mail, phone, or in person pickup. By using email or text, you accept the associated risks including the potential for unauthorized access, lack of end-to-end encryption, and possible exposure of health and billing information to unintended parties.
I consent to electronic delivery.
Date

MonthDayYear

Hour MinutesAM/PM Option
Is the patient under 18 years of age or have a legal representative?
Patient Name
Patient Email
Patient Signature
Parent or Legal Representative Name
Parent or Legal Representative Signature
Prescription Receipt
If you do not consent to electronic delivery, please sign below to acknowledge receipt of your prescription(s) after completing your eye examination. For contact lenses, prescriptions are finalized after successful completion of insertion and removal training.
Patient Signature
Parent or Legal Representative Signature
Should be Empty:

Prescription Receipt