Consent to Medical Treatment of Unattended Minors

Consent to Medical Treatment of Unattended Minors

This form allows parents or guardians to give consent for medical treatment of unattended minors in case of emergencies.
To Parents and Guardians:

At City of Vision Eye Care, we prioritize the health and well-being of every patient. We value your trust in us to care for your minor child and aim to provide the best possible healthcare.

General Consent Requirement:

We require parental or guardian consent to treat minors (under 18). Given that parents often have other commitments, we understand you may not always be able to accompany your child to appointments. If a minor arrives alone or with an adult who isn't a parent or guardian, they must have written consent for treatment. Without this, the appointment will be rescheduled.

Consent Form:

To ensure your child's appointments are not delayed, we offer a consent form. Once completed by a parent or guardian, this form will be kept in your child's medical record. It authorizes us to provide necessary routine and medical treatment, including dilation and/or digital imaging such as the Optomap is required. If a teenager will be driving themselves to the appointment, an Optomap must be performed instead of dilation drops. This consent remains effective until revoked in writing.

Exceptions:

By law, minors can consent to certain healthcare services without parental consent if they are emancipated, married to someone 18 or older, or in emergencies.

We are committed to providing healthcare in the best interest of your child. For questions, please contact us before your child’s appointment.
I, Parent/Guardian Name* the parent or legal guardian of the unattended minor, do hereby authorize the physicians at City of Vision Eye Care to perform the medical treatment as per the statements. I have read and acknowledge that decisions can be made by my unattended minor or designated proxy, as I have designated on the following page.

Patient and/or Proxy Name(s)
Patient's Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Patient's Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Patient's Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Parent/Guardian's Name*

First NameLast Name
Parent/Guardian's Number*
I, the parent, or legal guardian of the patient named above, do hereby authorize the physicians at City of Vision Eye Care to perform the medical treatment as per the statements above when accompanied by either of the following named adult persons over the age of 18
Proxy Adult's Name

First NameLast Name
Relationship to Child
Grandparent, Aunt, Uncle, Sibling, Family Friend
Proxy Adult's Name

First NameLast Name
Relationship to Child
Grandparent, Aunt, Uncle, Sibling, Family Friend
Signature for Authorization and Consent for Medical Treatment
This authorization is valid:
- For any medical procedures including the instillation of eye drops for eye pressure, dilation and/or Optomap Retinal Photography (typically not covered by insurance)
- Contact lens evaluation, fitting, and prescription (typically not covered in full by insurance)
Signature*

Clear
Date

MonthDayYear
Date
Should be Empty:

Consent to Medical Treatment of Unattended Minors

To Parents and Guardians:

General Consent Requirement:

Consent Form:

Exceptions:

Patient and/or Proxy Name(s)

I, the parent, or legal guardian of the patient named above, do hereby authorize the physicians at City of Vision Eye Care to perform the medical treatment as per the statements above when accompanied by either of the following named adult persons over the age of 18

Signature for Authorization and Consent for Medical Treatment