Minor Patient Waiver Form

Minor Patient Waiver Form
Due to medical-legal reasons, we cannot have patients under the age of 18 unattended in our office.

If you allow your child to be at our office without your supervision, we are not responsible for supervising your child while he/she is in our office.

By signing below, you agree that Huntley Eye Care, LLC will not be legally liable for any issues (medical or accidental) that should arise regarding your child while he/she is present in our office.

We need an emergency contact number so that we may reach you while your child is in our office. If deemed necessary and we are unable to reach you, you are giving us consent to call 911 for emergency.
Child Name*

First NameLast Name
Date of Exam*

MonthDayYear
Date
Name of Adult who will be accompanying child in our office*

First NameLast Name
By signing below, you also give consent to this Adult to make all medical and financial decisions for the child while they are in our office.
Parent/Guardian Name*

First NameLast Name
Parent/Guardian Signature*

Powered by Jotform SignClear
Emergency Contact Phone Number*
Date*

MonthDayYear
Date
Should be Empty: