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New Patient and Existing Patient Consent Form

Please note: This form must be completed in full before you can submit it.
If there is nothing to list, write “N/A” (not applicable).

  • Receipt of Notice of Policy Practices & Consent Form

    Effective date of notice: April 1, 2003

    In the course of providing service to you, we create, receive and store health information that identifies you. It is often necessary to use and disclose this health information in order to treat you, to obtain payment for our services and to conduct health care operations involving our office.

    The Notice of Privacy Practices you have been given describes these uses and disclosures in detail. You are free to refer to this notice at any time before you sign this form.

  • DateNames of those individuals allowed to receive personal patient information, including glasses and contact lensesRelationship to PatientDate of BirthAny Restrictions? 
  • I have read this document and I understand it. I consent to the use and disclosure of my health information for purposes of treatment, payment, and healthcare operations. I acknowledge that I have received the Notice of Privacy Practices from ESTRELLA MOUNTAIN EYE CARE, and I allow those listed above to receive (limited) personal patient information in my absence.

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