Patient Acknowledgment of Receipt of Privacy Practices and Consent/Limited Authorization & Release Form for Vision First Name * First Name Last Name Please List Any Other Parties Who Can Have Access To Your Health Information: This Includes your spouse, children, step parents, grandparents, and any care takers who have access to this patient's records. Name: First Name Last Name Relationship Phone Number (###) ### #### Name: First Name Last Name Relationship Phone Number (###) ### #### Name: First Name Last Name Relationship Phone Number (###) ### #### Name: First Name Last Name Relationship Phone Number (###) ### #### Name: First Name Last Name Relationship Phone Number (###) ### #### General Questions How do you want to be addressed when summoned from the Reception area? First Name Only Proper Surname Other Please select your preferred method of communication: Home Phone Cell Phone Text Message Email Can we leave automated reminders on your home or cell phone? Yes No Can we leave messages letting you know your glasses and contacts are ready? Yes No Thank you!