Permission For Treatment For Your Child

"Grandparent" Permission To Treat Form

complete this for to authorize a non-guardian adult to take your child to Bright Eye Consultants for medical care
please complete a seperate form for each child
Power of Attorney for Consent to Medical Care for a Minor
Patient Information
Patient Name*

First NameMiddle NameLast NameSuffix
Date of Birth*

MonthDayYear
Date
Patient Gender*

MaleFemaleOther
Patient Phone*
Please enter a valid phone number.
Patient Phone 2nd
Please enter a valid phone number.
Patient Social Security Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Parent or Authorized Signer
Signer's Relationship to Patient*

Birth ParentLegal GuardianMedical Power of AttorneyOther
Parent or Authorized Signer*

First NameMiddle NameLast NameSuffix
Parent or Authorized Signer Phone Number
Please enter a valid phone number.
Parent or Authorized Signer Email Address*
example@example.com

Non-Guardian Adult to be Authorized to Accompany Patient for Medical Care Decisions*

First NameMiddle NameLast NameSuffix
Non-Guardian Adult's Relationship to Patient*

GrandparentAunt / UncleSiblingHome Health AidGovernment OfficialNanny / Baby Sitter / Au PairOther

"Grandparent" Permission To Treat Form