CONSENT TO TREAT MINOR PATIENT WITHOUT PARENT OR GUARDIAN PRESENT

CONSENT TO TREAT MINOR PATIENT WITHOUT PARENT OR GUARDIAN PRESENT

Des Moines Eye Surgeons must receive permission from a child's parent or legal guardian before providing treatment in non-urgent situations. This form gives us legal permission to treat your child in the event that you cannot accompany them to the clinic for their appointment. If the party accompanying your child does not present this information, treatment may be denied. This consent only applies to minor's age 16+
Parent or Guardian's Name*

First NameLast Name
Patient's Name (Minor)*

First NameLast Name
Patient's DOB (Minor)*

MonthDayYear
Date
Routine/Medical Eye Care, which will include vision check, refraction, dilation of pupils, examination by a provider, and any other treatment previously discussed and agreed upon by the parents/legal guardian including testing that has been scheduled or testing that is determined to be needed by the provider upon examination.

Emergency or Urgent Care as determined by provider upon examination
I grant party accompanying minor *to arrange for and authorize routine and emergency treatment at Des Moines Eye Surgeons on Date . The party accompanying the minor will be responsible for communicating all treament discussions/ decisions to the parent/guardian. Des Moines Eye Surgeons and its providers will not hold a separate phone discussion with the parent/guardian after the visit. Signature Date
I grant consent for the minor to receive routine and emergency treatment at Des Moines Eye Surgeons without an accompanying adult. This consent only applies to minor's age 16+ Signature Date

I certify that the minor is age 16+ Signature
Should be Empty: