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.
Please list any of the responsible individuals that you will allow personal information, glasses, or contact lenses to be released to by our office. Proper identification will be documented whenever information is released to any of the people listed below. Examples of those individuals might be: spouse, significant other, the other parent, older sibling(s), grandparent(s), stepparent, aunt/uncle, or other caregiver. Only the minimum necessary information will be provided.
Date Names of those individuals allowed to receive personal patient information, including glasses and contact lenses Relationship to Patient Date of Birth Any 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.
Patient Legal Name*
First Last
Date*
Signature of Patient, Parent, Spouse, Significant Other, Other designated individual*
Date*

New Patient and Existing Patient Consent Form

Request an Appointment

Reason?*
Preferred Date/Time*
New Or Returning?*
New patient
Returning
Name*
First Last
Confirm*
By Phone
By Email
Phone*
Best Time to be Reached for Confirmation*

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Email*

Phone
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Estrella Mountain Eye Care PLLC