Consent to Treat Minor

Griswold Eye Care must receive permission from a child’s parent or legal guardian before providing treatment or evaluation. This form gives our office the legal permission and consent to treat your child in case you cannot accompany them. However, they must be accompanied by someone over the age of 18. That individual must be authorized below.

Please Note: - A parent/legal guardian MUST be present for their child’s first visit to Griswold Eyecare. Unless otherwise authorized by Dr. Simmons. A new “Consent to treat unaccompanied minor” form is required for each visit that a minor will be seen without his/her parent/legal guardian. Please send current insurance information and co-pay (if applicable) to the appointment with your child or the party accompanying them.

Patient Name: First Name* Last Name*
Date of Birth: Date* Date of appointment: Date*

I, First Name* Last Name* , grant First Name* Last Name* (an adult Parent/Legal Guardian Accompanying Party into whose care, the minor has been entrusted) to arrange for and authorized routine and emergency treatment at Griswold Eye Care. This authorization grants consent to examination, treatment, eyedrops or diagnosis.

Check One:*

ParentLegal Guardian

Note: If Legal Guardian box is checked, documentation establishing guardianship must be provided or on record in order to comply with the above request

Printed Name: First Name* Last Name* Today's Date: Date*

Parent/Legal Guardian Signature Below

Signature*

Today's Date*

Date

In case of Emergency, I can be reached at:
Home:  Area Code   Phone Number  Primary
Work:   Area Code   Phone Number Primary
Cell:   Area Code   Phone Number   Primary