THIS IS A SUMMARY OF OUR NOTICE OF PRIVACY PRACTICES, WHICH DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.

Our Notice of Privacy Practices provides information about how we may use and disclose protected health information about you. The notice contains Patient rights section describing your rights under the law. You have the right to review our Notice before signing this Consent. You may obtain a copy by asking the front desk. The terms of our Notice may change. If we change our Notice, you may obtain a revised copy.

Our pledge to protect your privacy:
Skyline Lasik is committed to protecting the privacy of your medical information. Your care and treatment are recorded in a medical record. So that we can best meet your medical needs, we share your medical record with the providers involved in your care. We will not use or disclose your information for any other purpose without your permission. Please note Skyline Lasik LLC does not accept any form of Medical or Vision Insurance of any kind. Skyline Lasik LLC is strictly a cash pay business that only provides elective procedures that are not deemed medically necessary in any way.

Patient Rights - You have the following rights regarding your medical information:

to request to inspect and obtain a copy of your medical records, subject to certain limited exceptions.
to request to add an addendum to or correct your medical record.
to request an accounting of disclosures of your medical information.
to request restrictions on certain uses or disclosures of your medical information; to request that we communicate with you in a certain way or at a certain location; and to receive a copy of the full version of our Notice of Privacy Practices.

We may use and disclose medical information about you for the following purposes:

to provide you with medical treatment and services.
for functions necessary to run Skyline Lasik LLC and assure that our Patients receive quality care.

ACKNOWLEDGEMENT OF RECEIPT OF SUMMARY NOTICE OF PRIVACY PRACTICES

By signing this form, you consent to our use and disclosure of protected health information about you for treatment. You have the right to revoke the Consent in writing, signed by you. However, such a revocation shall not affect any disclosures we have already made in reliance on your prior Consent. provides this form to comply with the Accountability Act of 1996 (HIPAA). I acknowledge that I have read this form. I understand that electronic (online) communication has risks, including possible risks not mentioned above. I agree to abide by the policies described above. I agree to use reasonable judgment about any messages I send or receive. I do not have any unanswered questions about what this Agreement covers.

Before your consultation:

Stop wearing soft contacts for 3–5 days prior to
Stop wearing hard/RGP/Scleral lenses 2 weeks prior to
Wear or Bring glasses to your consult.
Bring a valid photo ID
Consultation takes 1-1.5 hours and eyes will be dilated.

Cost

No insurance collected (surgery is elective)
Consultation is complementary, unless you’ve had prior vision correction surgery in one or both of your eyes. Then a $200 non-refundable fee will be collected.
Surgery scheduled for 90+ days after the initial consultation, repeat evaluation and testing is required. A $100 non-refundable fee will be collected at that time.

By submitting this form you consent to receive phone calls, text messages and emails from Skyline LASIK. It is not a condition of purchasing any goods or services. You can opt out at any time, message/data rates may apply, and opting-in includes acceptance of the Privacy Policy and Terms of Use. Communications through our website or via email are not encrypted and are not necessarily secure. Use of the internet or email is for your convenience only, and by using them, you assume the risk of unauthorized use.