Eye Q Vision

EyeQ Vision Patient Check-In

Please complete this form when you arrive for your appointment

Please prepare to wear your protective mask during your visit inside. If you do not have a mask, don't worry, we will provide you with one!

- Please enter your first name.
- Only letters and apostrophe are allowed.
- Please enter your last name.
- Only letters, spaces, and apostrophe are allowed.
- Please enter your email following the pattern mentioned above.
- Please enter your phone number.
- Only numbers, periods, plus sign, hyphen, underscores, and parenthesis are allowed.
- Please enter your vehicle make, model, and color.
- Please select one of the above.
- Please select one of the above.
- Please select one of the above.
- Please select one of the above.
- Please enter your name or guardian name.
- Please check to acknowledge.
- Please enter only numbers and periods.

I understand that I have certain rights to privacy regarding my protected health information. These rights are given to me under the Health Insurance Portability and Accountability Act of (HIPAA). I understand that 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 treatment);
  • Obtaining payment from third party payers (e.g. my insurance company);
  • The day-to-day healthcare operations of your practice.I have also 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 of this notice.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 health care operations, but that you are not required to agree to these requested restrictions. However, if you do agree, you are then bound to comply with this 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 I revoke this consent is not affected.
- Please agreen to HIPPA consent.
- Please select one of the above.
Please correct the errors highlighted in red above.