Skip to main content

Custom Contacts/Scleral Myopia Control Dry Eyes

various_colorful_sunglasses_row_1280x480
Home » Contact Us » HIPAA Consent Form

HIPAA Consent Form

HIPAA Consent Form

Acknowledgement of Receipt of HIPAA Notice of Privacy Practices
  • Date Format: MM slash DD slash YYYY

  • OR
  • Please Note: It is your right to refuse to sign this Acknowledgement.
  • Date Format: MM slash DD slash YYYY