CONSENT FOR TREATMENT OF MINOR
Name of Minor
*
Date of Birth
*
-
Month
-
Day
Year
Date
Name of parent or legal guardian
*
Please select one option
*
Parent
Legal Guardian
I, (parent or legal guardian) the undersigned, grant permission for care, treatment, and/or dilation, which may include administration of any necessary drops given to my child in relation to today's appointment.
*
Yes, I consent
No, I do not consent
I understand that Dr. Norris has informed me of the necessary treatment to the minor stated.
*
Yes, I understand
No, I do NOT understand
In case of an emergency, an effort will be made to reach me at the provided phone numbers.
*
-
Area Code
Phone Number
-
Area Code
Phone Number
If I am unable to be reached or located within a reasonable time I give my consent to provide the needed medical or surgical services to my child.
*
Yes, I consent
No, I do NOT consent
Medical Information
Name of Primary Doctor
Contact Number of Primary Doctor
-
Area Code
Phone Number
Any known allergies:
*
Medications child is currently taking:
*
Any other important information the optometrist should be aware of:
Date
*
-
Month
-
Day
Year
Date
Name
*
I have read and fully understand the above information and consent permission of care, treatment, and/or dilation, which may include administration of any necessary drops given to my child in relation to today's appointment.
*
Submit
Should be Empty: