Consent to Treat Minor (Commerce)

Commerce Family Eyecare

1871 N. Elm St. Commerce, GA 30529

CONSENT TO TREAT MINOR DEPENDENT

By signing this form you are hereby giving Commerce Family Eyecare and the doctors therein permission to see and treat your minor/dependent child without you being present.

Your signature, as the minors parent/guardian, on this document takes place of any and all signature required areas on our offices patient forms.
Patient Name*

First NameLast Name
Parent/Guardian Name*

First NameLast Name
Date*

MonthDayYear
Date
Relationship to Patient*
Signature*

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Date*

MonthDayYear
Date
Parent/Guardian ID*

Cancelof
Insurance Card*

Cancelof
Should be Empty: