Clinic Policy & Signature
Review the Retina of North Texas patient policies and create a completed, printable patient policy signature page.
Please review before your visit.
Please review the full clinic policy document before your appointment. You may view or download the policy and the separate signature page below.
Clinic policy documents
The full policy includes the Notice of Privacy Practices, Notice of Financial Policy, Patient Acknowledgement, Communication Consent, and HIPAA access information.
How the digital signature page works
Complete the fields on this page and sign in the signature box. The completed signature page preview will populate below. Use Print / Save as PDF to print or save the populated page as a PDF.
Note: This static website does not transmit the form electronically. Please print, save, or bring the completed page as directed by the office.
Complete digital acknowledgment
Fill out the fields below. The preview will update automatically and will match the attached signature page language.
Completed Signature Page Preview
This preview populates from the fields above. Use the print button to print or save this page as a PDF.
EYE CENTERS OF NORTH TEXAS, PLLC
RETINA OF NORTH TEXAS
PATIENT POLICY SIGNATURE PAGE
Patient Chart Number:
I ACKNOWLEDGE THAT I HAVE REVIEWED, UNDERSTAND, AND ACCEPT THE PATIENT ACKNOWLEDGEMENT AND COMMUNICATION CONSENT, FINANCIAL POLICY, AND PRIVACY PRACTICES POLICY OF THE EYE CENTERS OF NORTH TEXAS, PLLC DOING BUSINESS AS RETINA OF NORTH TEXAS. ALL OF MY QUESTIONS HAVE BEEN ANSWERED.
Contact Retina of North Texas
Phone: 214-233-6170 | Fax: 214-241-4947
E-mail: info@retinanorthtexas.com.