By signing this form, you attest to opting in to sharing of your medical, financial and health insurance information with
Midwestern University's Eye Institute for the purposes of vision screenings and services. This form also allows NATIVE
HEALTH to receive results related to your vision appointment. Please be aware that if you do not opt into this information
sharing, you will not be able to participate the Midwestern University's Eye Institute Eye Exams and Eyeglass program.