Welcome to Eyebright Optometry!
PLEASE STAY IN YOUR CAR AND GIVE US A CALL WHEN YOU ARRIVE.
Per the department of health guidlines our healthcare clinic still requires masks to be worn at all times for ages 2 and older.
If you are NOT the primary member on the plan please provide their information below.
In accordance with the Health Insurance Portability and Accountability Act (HIPAA) I read the copy of Eyebright Optometry Notice of Privacy (on the office website FORMS page) and understand I may request a copy of records. The Notice of Privacy Practices is subject to change. Update policies will be available at the front desk.
I authorize the payment of health care benefits to this office. I understand I am responsible for payment of any charges not covered by insurance.
I authorize any holder of medical information about me to be released and/ or request my medical information with other health care professionals for the purpose of consultation and referral as needed for my health care.
Please print name if signing for a minor.