LFLA Vision Van Consent Form '23-'24

EYE THRIVE

VISION EXAM CONSENT FORM
FREE eye EXAM and GLASSES for your child! Eye Thrive is proud to operate a Mobile Vision Clinic that provides eye exams and prescription glasses to children throughout our community at no cost. This free health service is authorized by your child's school.
Child's Name*

First NameLast Name
Child's Date of Birth*

MonthDayYear
Date
Child's Grade Level
Child's School
Child's Gender

MaleFemalePrefer Not to SayOther
Child's Ethnicity

Hispanic or LatinoNot Hispanic or Latino
Child's Race

American Indian or Alaska NativeAsianBlack/African AmericanWhite/CaucasianNative Hawaiian or Other Pacific IslanderPrefer Not to SayOther
Is your child enrolled in Medicaid?

NoYes
If yes, my child's Medicaid ID is
Is your child enrolled in Free or Reduced Lunch?

NoYes
Home Street Address
City
State
Zip Code
Your signature below certifies that you are the parent/legal guardian of the minor listed and authorizes our licensed optometrist and staff to conduct an eye examination (with drops if needed) and prescribe and dispense eyewear (if needed You are also authorizing full disclosure of the results of your child's eye examination. This information may be shared with the following individuals: yourself, your child's school nurse, and any specialist we may refer your child to for follow-up and continuity of care. You are also giving permission to verify Medicaid eligibility and, if applicable, bill Medicaid for the eye examination only.
Parent/Guardian SIGNATURE*

Clear
Date*

MonthDayYear
Date
Parent/Guardian Printed Name*
Relationship to Patient*
Parent/Guardian Phone*
Parent/Guardian Email*
example@example.com
Your signature below allows your child to be photographed or filmed solely for the promotion of Eye Thrive.
Parent/Guardian SIGNATURE

Clear
Date

MonthDayYear
Date
Has your child ever received an eye exam?

YesNo
If yes, was it from Eye Thrive?

YesNo
Has your child ever been prescribed glasses?

YesNo
If so, how long ago?
Does your child wear glasses now?

YesNo
Does your child complain or blurry vision?

YesNo
Does your child have diabetes?

YesNo
Has your child ever injured or had surgeries on their eyes?

YesNo
If yes, please explain
Please list any medications your child is currently taking.
Please list any food or medication allergies.
Please list any diagnosed medical conditions.
Please list any family history of eye disease.
Should be Empty:

EYE THRIVE