Privacy Notice - Eccarius Eye Clinic

Privacy Notice

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

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: *	Yes
Patient's First Name: *
Patient's Last Name: *
Date of Birth: *
Today's Date: *