Patient Intake Form

Patient Intake Form

Our Notice of Privacy Policy provides information about how we may use and disclose protected health information about you. The Notice contains a Patient Rights section describing your rights under the law. You have the right to review our Notice before signing this Consent.

The terms of our Notice may change. If we change our Notice, you may obtain a revised copy by contacting our office. You have the right to request that we restrict how protective health information about you is used or disclosed for treatment, payment, or health care operations. We are not required to agree to this restriction, but if we do, we shall honour that agreement.

 

By signing this form, you consent to our use and disclosure of protected health information about you for treatment, payment, and healthcare operations. You have the right to revoke this Consent, in writing, signed by you. However, such a revocation shall not affect any disclosures we have already made in reliance with your previous consent. Any personal information you voluntarily provide is protected under Alberta’s Personal Information Protection Act. This means that, at the point of collection, you will be informed that your personal information is being collected, the purpose for which it is being collected and that you have a right of access to the information.

I understand that I am responsible for fees associated with the eye examination performed including those not covered by my vision insurance plan, if any. I further understand that payment is due on the day of service unless other arrangements have been made prior to the treatment being performed.


I consent that my contact information that I have provided (address, phone number, and e-mail) to be used for correspondence from Bridgeland Crossings Optometry to myself, to other health care providers if necessary, and to any insurance providers for direct billing purposes. I also consent information may be used to send appointment reminders, updates, and promotional material by letter mail, email, phone, or text message. 

I understand that the email provided is my own, and may be used to send private information in a secure manner.

I understand that information collected may be used for further patient management (referrals, reports, 3rd party requests with your consent), educational purposes, or for future analysis and comparison at future visits.