Henry Ford OptimEyes – Minor Consent – Patient Registration Forms

Permission to consent for medical/optometric care to minor child or incapacitated adult.

Patient Information:
Name*
First Middle Last
Date of Birth*
Date Format: MM slash DD slash YYYY
Insurance type and Number*
Please bring the patient's insurance card to the visit.
Authorized Person:
A primary person and an alternate are recommended.
Authorized Primary's Name*
First Last
Authorized Primary's Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Authorized Primary's Phone*
Authorized Alternate's Name
First Last
Authorized Alternate's Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Authorized Alternate's Phone
Consent and Signatures:
To consent to an examination which may include dilation, contact lens fitting (including contact lens class and all subsequent follow-ups), vision therapy (VT follow-ups), diagnoses and/or treatment to be rendered to the patient on the advice of any Optometrist licensed to practice Optometry. This authorization shall be effective from the date signed but must not exceed six(6) months from the date signed.
Date*
Date Format: MM slash DD slash YYYY
Signature of Parent/Guardian*
Printed Name of Parent/Guardian*
First Last
Phone*

Patient Information: