Minor Child Consent (ALL)

CONSENT TO PROVIDE HEALTH CARE SERVICES TO A MINOR CHILD

This form is provided by Better Vision Family Eye Care to obtain consent from a parent or legal guardian for health care services to be provided to a minor child. I

First Name

Last Name

hereby consent to Better Vision Family Eye Care providing health care services for my child,

Minor First Name

Minor Last Name

as deemed necessary by our healthcare providers for the health and welfare of said minor child.

This consent includes, but is not limited to:

Eye examinations
Diagnostic testing (e.g., imaging)
Emergency anaphylaxis treatment (e.g., Epipen)
Administration of medications (e.g., Topical anesthesia, dilating drops)
Prescription of medications
Arrange or schedule health care services

This consent is effective from the date of signature and remains effective until revoked in writing.

Minor Child’s Information:

Minor First Name

Minor Last Name

Minor DOB:

Parent/Legal Guardian Information:

First Name

Last Name

DOB:

Relationship to Minor:

Phone Number

I also authorize the following individuals (e.g., grandparents, nannies) to bring my child to appointments and consent to treatment in my absence:

First Name

Last Name

Relationship

First Name

Last Name

Relationship

Known Drug Allergies:Known Drug Allergies:

Current Medications:

Primary Care Physician/Pediatrician:

I understand that by signing this form, I am giving Better Vision Family Eye Care the authority to provide healthcare services for my child as outlined in this document. I assume full responsibility for all costs incurred for medical treatment authorized under this consent.

Parent/Legal Guardian Signature:

Date:

Witness Signature:

Date:

Minor Child Consent (ALL)

CONSENT TO PROVIDE HEALTH CARE SERVICES TO A MINOR CHILD

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Minor Child Consent (ALL)

CONSENT TO PROVIDE HEALTH CARE SERVICES TO A MINOR CHILD

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