Privacy Statement

You have the right to review our privacy notice, request restrictions and revoke consent in writing after you have reviewed our privacy notice. Signing below signifies that you have had the opportunity to view the privacy notice by requesting a copy or reading a copy located in the waiting room and you agree to the privacy policy of our office.

By signing below you acknowledge you have read, understand and agree to the Advanced Eye Center Notice of Privacy Practices.

Printed Patient Name:

First Last

Signature of Patient or Guardian:

Date

Printed Name of Guardian (if applicable):

Signature of Office Representative:

Date

Please list the names of the persons to whom we may disclose the patient’s private health information and state how the individual is related to the patient:

Name:

Relationship:

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