Communication Form

Name: Atkinson Eye Care
Address: 2100 N Huntington Dr, Unit A, Algonquin, IL, 60102, US
Telephone: 847-854-5700
Price range: $000 - $300

Patient Name
First Last
Parent, if your child is under the age of 18, please sign for the following.
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Home Phone
Work Phone
Cell Phone*
Email Address
Is it okay for us to leave a text message on your cell phone?
- Yes
- No
Is it okay for us to leave a voice message on your phone?
- Yes
- No
Is it okay to email you?
- Yes
- No
Release of medical information:
I hereby authorize the release of my medical information to the following
Name
Relationship to Patient
Name
Relationship to Patient
Emergency Contact Only
Phone
Relationship to Patient
Patient/Parent Signature
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Date
MM slash DD slash YYYY