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
Child's Ethnicity
Child's Race

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

MonthDayYear
Date
Parent/Guardian Printed Name
Relationship to Patient
Parent/Guardian Phone
Format: (000) 000-0000.
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
Date

MonthDayYear
Date
Has your child ever received an eye exam?
If yes, was it from Eye Thrive?
Has your child ever been prescribed glasses?
If so, how long ago?
Does your child wear glasses now?
Does your child complain or blurry vision?
Does your child have diabetes?
Has your child ever injured or had surgeries on their eyes?
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