Privacy Notice

Please review the Privacy Notice by clicking the link below. Then, acknowledge receipt by filling out the form below.
Privacy Notice

 


PATIENT’S ACKNOWLEDGMENT OF RECEIPT
By checking this box, I hereby acknowledge that the Eccarius Eye Clinic Medical Information Privacy Notice is available for my review prior to receiving services through Eccarius Eye Clinic
Acknowledge: *
 
Patient's First Name: *
 
Patient's Last Name: *
 
Date of Birth: *
 
Today's Date: *