Thank you for choosing us for your eyecare needs. We are delighted to have you as a patient and appreciate the confidence you placed in us. Please take a moment to complete the following information. Any information we already have on file will appear on this form. Please review all completed areas to ensure that the information we have is current and accurate. If you have any questions, please do not hesitate to ask.
НІРАА . I have reviewed or recieved a copy of Becvar Optometry's Health Insurance Portability and Accountability Act (HIPPA). By sigining below, I authorize the disclosure of my health information as described in the form.
I give consent to receive a copy of my eyeglasses and/or contact lens prescription electronically.