4092 Danada Vision Center LLC

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  • Your signature acknowledges that you have read a copy or been given the opportunity to read Danada Vision Center Notice of Privacy Practices. Federal regulations (Health Insurance Portability and Accountability Act - HIPAA) Require we ask for your signature of receipt.
  • By signing this form I consent to treatment for myself and/ or on behalf of the minor for which this information pertains. I giver permission for the Doctor(s) to examine, diagnose and initiate treatment as deemed appropriate.I further, attest that I am the parent or legal guardian of the Minor and have the authority to authorize care and treatment. I agree to be responsible for all services rendered on my behalf or my dependents. I understand I am responsible for any and all fees my insurance does not cover. I understand that payment is due at the time of service unless other arrangements are made. I have read and agreed to Danada Vision Center's Financial Policy. Please understand, since an order for glasses is a custom prescription designed for each individual patient, once it is in progress, we will be unable to cancel the order.
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