foxeyecare.com - Consent to Treat Minor

Location*

Crabtree Valley Mall, Raleigh

4325 Glenwood Ave.
Raleigh, NC 27612
Located next to Lenscrafters

Berkeley Mall, Goldsboro

611A N Berkley Blvd, Berkeley Mall
Goldsboro, NC 27534
Located next to Lenscrafters

Friendly Shopping Center, Greensboro

642 Friendly Center Road
Greensboro, NC 27408
Located next to Lenscrafters

Four Seasons Town Center, Greensboro

330 Four Seasons Town Center
Greensboro, NC 27407
Located next to Lenscrafters

Hanes Mall, Winston-Salem

3320 Silas Creek Pkwy, Suite 300
Winston Salem, NC 27103
Located next to Lenscrafters

If the patient is a minor (under 18 years of age), please complete the information below then read and sign the following statement:

Patient’s Name:*

DOB:*

Date

Parent or Guardian:*

Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Home Phone: *

Please enter a valid phone number.

Work Phone:

Please enter a valid phone number.

Other:

Please enter a valid phone number.

Primary Insured:*

Employer:*

Insurance Co:*

Policy#:*

Group:*

Please initial on each line.
initial* Your insurance is meant to serve as a financial aid. We are happy to take assignment on your benefits. If you are not eligible for these benefits or are eligible for less than full coverage, your signature (at the bottom) indicates that you agree to be financially responsible for the balance not paid by your plan. (Contact lens wearers- Rarely will insurance plans cover the entire exam, contact lenses and professional fees for contact lens evaluations. Our office staff will make every effort to verify your benefits.)

VERIFICATION OF BENEFITS IS NOT A GUARANTEE OF PAYMENT

initial* I hereby grant permission to Fox Eye Care Group and/or to the Optometrist in charge of the exam to the above named minor to administer any treatment as may be deemed necessary to treat my child. I understand that I will be informed of the diagnosis, treatment, and possible risks and consequences of said treatment and do authorize the doctor(s) to proceed.

I*

allowwill not allow my child to be dilated.

(If not allowed, the doctor may require the patient to return on another day to complete the exam.)

I*

allowwill not allow my child to be fitted with contact lenses if a prescription is deemed necessary.

(If allowed, please provide an e-mail address or fax number for the contact lens policy:

Signature*

Date*

Date

Consent to Treat a Minor