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Chatsworth Elementary School

11/26/2019 01:30 PM – 07:00 PM
Note: Please register each person individually.


Patient Details

Appointment Details

If You do not have Vision Insurance, you can use your Optical Academy membership and pay only $30.00 for your Eye Exam, which can be paid at the event.
Payment will be due at the time of the event. Acceptable forms of payment include Cash or Credit.

Medical Provider

Insurance Provider


***Patients requesting a Contact Lens Exam are required to have had a contact lens fitting within the last 2 years

Comprehensive Eye Exam
Contact Lens Exam *Add $30

The privacy of your medical information is important to us. We understand that your medical information is personal and we are committed to protecting it. This notice will tell you about the ways we may use and share medical information about you. We also describe your rights and certain duties we have regarding the use and disclosure of medical information. Our Legal Duty-Law Requires Us to keep your medical information private and give you this notice describing our legal duties, privacy practices, and your rights regarding your medical information. Notice of Change to Privacy Practices: Before we make an important change in our privacy practices, we will change this notice and make the new notice available upon request. Use and Disclosure of Your Medical Information. The following section describes different ways that we use and disclose medical information. Not every use or disclosure will be listed. However, we have listed all of the different ways we are permitted to use and disclose medical information. We will not use or disclose your medical information for any purpose not listed below, without your specific written authorization. Any specific written authorization you provide may be revoked at any time by writing to us. For Treatment: We may use medical information about you to provide you with medical treatment or services. We may disclose medical information about you to doctors, nurses, technicians, medical students, or other people who are taking care of you. We may also share medical information about you to your other health care providers to assist them in treating you. Notifications: We may use and disclose medical information to notify or help notify: a family member, your personal representative or another person responsible for your care. We will share information about your location, general condition, or death. If you are present, we will get your permission if possible before we share, or give you the opportunity to refuse permission. In case of emergency, we will share only the health information that is directly necessary for your healthcare, according to our professional judgment. We will also use our professional judgment to make decisions in your best interest about allowing someone to pick up medicine, medical supplies, x-ray or medical information for you. Acknowledgement of Receipt and General Consent I acknowledge that I have reviewed a copy of Optical Academy, Your Eye Exam in Your School. I further consent to the release of my health information for purposes of treatment, payment and health care operations and as authorized or required by law under the circumstances described in the Notice of Privacy Practices. We will send you notifications/reminders of you the event you have registered via email and sms. You may receive email updates about Optical Academy. You may subscribe anytime by clicking unsubscribe in the email you receive, or responding STOP via sms.

By submitting this electronic form you confirm that you have read this agreement and agree to its terms and also serves as an acknowledgement that you have received the HIPPA notice form described above.