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Arizona Primary Eye Care
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Arizona Primary Eye Care
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Authorization to Discuss

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Authorization to Verbally Discuss Protected Health Information*Note: This form is optional. In order for this form to be valid, all information must be completely filled out.

MM slash DD slash YYYY

I hereby give permission for Arizona Primary Eye Care and affiliates to verbally discuss the following medical and billing information about me (check all that apply):

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Arizona Primary Eye Care and affiliates has my permission to discuss the above information with:

I understand that I may cancel this permission at any time by notifying Arizona Primary Eye Care in writing, however, canceling permission will not affect any information that has already been released.
I understand that I do not have to sign this form and that I should only sign if I want my medical provider or my clinic to share my information with someone.

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This field is for validation purposes and should be left unchanged.

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Client Testimonials

⭐️⭐️⭐️⭐️⭐️

Dr Nichols and Cindy Valencia are awesome! They truly care and listen to customers needs. The service is amazing and welcoming!

Veronica W.

⭐️⭐️⭐️⭐️⭐️

My kids get their glasses here ages 5-15. Always friendly staff from the moment you walk. We have always had a great experience. I would definitely recommend this place.

Alicia B.

⭐️⭐️⭐️⭐️⭐️

The Dr. was great.. clear, concise and kind. The rest of the staff took her lead in those qualities as well.

Heidi L.

⭐️⭐️⭐️⭐️⭐️

I’ve been to four different optometrists in the last 20 years. This is by far the best. Prompt, thorough and professional from reception to check out. Very well trained staff.

Kim N.

⭐️⭐️⭐️⭐️⭐️

I would give 10 stars if I could. Fast, friendly and competent staff. Everyone is amazing. Michelle and Justin helped my husband Bob and I pick the perfect frames. We are 1000% satisfied repeat customers.

Kathie H.

⭐️⭐️⭐️⭐️⭐️

Very pleasant and professional! Now, if only I could find and MD with qualities to match these folks!

Roger O.
Services
  • EYE EXAMS
  • EYE EMERGENCY/INJURY
  • KIDS VISION
  • ORDER CONTACTS
  • FRAMES & LENSES
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