Phone: (941) 351-1200
Please read over and fill out the following form completely prior to your appointment.
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Please fill out the information below completely regarding your medical information.
Consent for Medical Treatment Disclaimer
By signing below, I hereby acknowledge that I have read this form and I understand its contents and agree to all of the provisions contained herein, which I agree shall be applicable to any and all care and treatment provided by Retina Care Consultants, P.A. within one (1) year from the date signed. Furthermore, I acknowledge that I have been given the opportunity to read and ask questions about the information contained in this form, and that I either have no questions or that my questions have been answered to my satisfaction.
Notice of Privacy Practices Disclaimer
By signing below, I hereby acknowledge that I have read and received a copy of the Notice of Privacy Practices set forth by Shane Retina, and I understand and agree to the policies described in that document.
Financial Policy Disclaimer
By signing below, I hereby acknowledge that I have read and understood the above Financial Policy from Shane Retina, and agree to abide by all aspects of this agreement.