PLEASE READ CAREFULLY AND SIGN
I understand that every visit my eyes will be dilated. I
understand that it is legal to drive dilated, but I may be more
comfortable if I have a driver.
I understand that I am financially responsible for all charges
I request that payment of authorized insurance benefits be
made to Retina Consultants of Nevada for any services furnished to me.
A handling fee will be charged for personal checks returned from the bank for any reason.
This consent acknowledges and permits Retina Consultants of
Nevada to use and disclose Protected Health Information (PHI) to carry out treatment, payment or healthcare operations.
Retina Consultants of Nevada contacts patients by phone call, email and/or text message.