Patient Intake Form

  • Your Information

  • Date of Birth*
     - -
  • Format: (000) 000-0000.

  • Your Eye History

  • Do you wear eyeglasses?*
  • Do you wear contact lenses?*
  • Have you ever had eye surgery?*
  • Have you ever had an eye injury?*
  • Have you ever been diagnosed with
  • Have you recently had

  • Family Eye History

  • Has anyone in your family had

  • Your Medical History

  • Have you ever been diagnosed with
  • Do you have any allergies?*

  • HIPAA Privacy Policy Patient Consent

    I understand that I have certain rights to privacy regarding my protected health information under the Health Insurance Portability and Accountability Act of 1996 (HIPAA). By signing this consent, I authorize you to use and disclose my protected health information to carry out:

    • Treatment, including direct or indirect treatment by other healthcare providers involved in my care
    • The day-to-day healthcare operations of your practice

    I have been informed of and given the right to review and secure a copy of your Notice of Privacy Practices, which contains a more complete description of the uses and disclosures of my protected health information and my rights under HIPAA. I understand that you reserve the right to change the terms of this notice from time to time, and that I may contact you at any time to obtain the most current copy.

    I understand that I have the right to request restrictions on how my protected health information is used and disclosed to carry out treatment, payment, and healthcare operations, but that you are not required to agree to these requested restrictions. However, if you do agree, you are bound to comply with that restriction.

    I understand that I may revoke this consent, in writing, at any time. However, any use or disclosure that occurred prior to the date of revocation is not affected.

  • Date of Signature
     - -
  • Should be Empty: