Patient Portal Electronic Consent Form
EyeCare Partners offers the convenience of accessing your eyeglass/contact lens prescription and other health
information through our secure portal. By consenting to use our patient portal, you agree to receive and manage
your prescriptions and related information electronically. Please read and agree to the following terms before
providing your consent.
Electronic Delivery Method:
I consent to access my prescription (eyeglass/contact lens) and other health information through the
EyeCare Partners patient portal.
I understand that my prescription and related information will be available for download and review in the
portal and may include PDF files or other secure electronic formats.
Right to Withdraw Consent:
I understand that I can withdraw my consent to use the patient portal at any time by contacting EyeCare
Partners in writing or via phone. Upon withdrawal, I may request to receive my prescription and health
information in paper form.
Responsibility for Accuracy:
I confirm that the email address and other contact information provided for the patient portal account are
accurate. I am responsible for ensuring that my login credentials and account information are secure.
I will notify EyeCare Partners if my email address or contact information changes, or if I no longer wish to
use the patient portal.
Privacy and Security:
I understand that EyeCare Partners will take reasonable measures to protect the confidentiality of my
information within the patient portal. However, I acknowledge that electronic communications may have
inherent risks, including unauthorized access to personal data if not properly secured.
I am aware that it is my responsibility to keep my login information confidential and to log out of the patient
portal after each session.
Alternative Delivery:
I understand that I have the right to request a paper copy of my prescription and health information at any
time, and EyeCare Partners will provide this information upon request without additional cost or conditions.
I consent to:
I wish to receive my prescriptions electronically via the Patient Portal today
I wish to receive a paper copy and was given one today.
I wish to decline my prescriptions and was not given one today.
I have read and understand the information provided in this form.
Patient's Name: ___________________________________________________________________________________
Date of Birth: ______________________________________________________________________________________
Email Address: ____________________________________________________________________________________
Patient’s/Guardian Name: __________________________________________________________________________
Patient's/Guardian Signature: ______________________________________________________________________
Date: _____________________________________________________________________________________________
Office Use Only
Consent Obtained By (Staff Name): _________________________________________________________________
Date: _____________________________________________________________________________________________
