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5 Swan Lake Blvd, Unit 7
Markham, ON L6E 0K7

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Eclaim Consent Form

 

Electronic transmission authorization and consent form

Provider: Dr. Yilei Wang, Optometrist, Markham Eye and Vision Care

Address: 5 Swan Lake Blvd., Unit 7 Markham ON L6E 0K7; Phone: 905-471-8118; Fax: 905-471-9119

Patient:

Name(Required)
MM slash DD slash YYYY

Consent to collect and exchange personal information

Purpose(Required)
Authorization and consent(Required)
Benefit assignment form(Required)
MM slash DD slash YYYY

All information contained herein is protected by privacy laws including the Personal Information Protection and Electronic Documents Act (PIPEDA) and all the corresponding provincial legislation. All users agree to protect the personal health information contained herein from unauthorized use, disclosure, loss, theft, or compromise in accordance with the above noted laws and with at least the same care employed to protect their own confidential information. Any unauthorized access, disclosure or use of this information is illegal.
MM slash DD slash YYYY

 

 

COVID-19 Notes

Thank you for entrusting Markham Eye and Vision Care .

Following the guidelines of College of Optometrists of Ontario, and the Directive of Chief Medical Officer of Health, we try our best with preventative measures to protect our patients and team against the spread of COVID-19.

Thank you for your understanding and cooperation.

New procedures for your appointment and visits.