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Patient Registration Form

/Patient Registration Form
Patient Registration Form 2017-03-05T16:53:57+00:00

Patient Registration Form

Prior to your office visit, please follow the instructions below to complete the Patient Registration Form.

INSTRUCTIONS:

  1. Download and save the Patient Registration Form PDF file.
  2. Open the Patient Registration Form PDF file.
  3. Print the Form.
  4. Fill out the Patient Form completely.
  5. Please sign the Form and bring it with you to your office visit. Thank you.

* The Patient Registration Form is Adobe Acrobat PDF format. Adobe Acrobat Reader. Adobe PDF Reader

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The Big Savings LASIK Event!

This is your opportunity to have iLASIK with Dr. Boutros, ranked one of the top LASIK surgeons in Virginia, at our lowest price of the entire year!! That’s big savings, $2500 savings… off iLASIK with advanced technology that can not only correct nearsightedness and farsightedness but your astigmatism too.

So, if you’ve been thinking about LASIK, about making a big improvement in your life, you need to call before June 30th to schedule your FREE LASIK consultation because, if we didn’t mention it…this is really big!

Call (888) 844-2020 or Click here to Schedule Your Free Consultation.

HIPAA Notice of Patient Privacy Practices

Our Notice of Privacy Practices 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 protected 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 honor that agreement.

By signing this form, you consent to our use and disclosure of protected health information about you for treatment, payment and health care 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 on your prior Consent. The Practice provides this form to comply with the Health Insurance Portability and Accountability Act of 1996 (HIPAA).

The patient understands that:

  • Protected health information may be disclosed or used for treatment, payment or health care operations
  • The Practice has a Notice of Privacy Practices and that the patient has the opportunity to review this Notice
  • The Practice reserves the right to change the Notice of Privacy Policies
  • The patient has the right to restrict the uses of their information but the Practice does not have to agree to those restrictions
  • The patient may revoke this Consent in writing at any time and all future disclosures will then cease
  • The Practice may condition treatment upon the execution of this Consent.

For more in-depth details regarding HIPAA and our Privacy Practices, please read: Notice of Privacy Practices  (PDF)

If you have questions about any of this information or the practices of this web site please send an email to info@TheEyeCenter.com 

The Eye Center
1.888.844.2020

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Website Privacy Policy

We understand and value your privacy. The Eye Center does not sell or distribute contact information. All data collected through any website form is used only to provide you with better customer service.

At The Eye Center, we leverage cookie based technology to group users into re-marketing audiences who have expressed an interest in our procedures by accessing key pages throughout our website. We do not collect any personally identifying information with this cookie. Audience members may be shown  The Eye Center text and/or image ads on any 3rd party Internet sites or applications for a limited period of time. Visitors may opt out of re-marketing by visiting Ads Settings. 

The Eye Center
1.888.844.2020

Thanks for signing up. You must confirm your email address before we can send you. Please check your email and follow the instructions.
We respect your privacy. Your information is safe and will never be shared.
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