Henry Ford Optimeyes - Minor Consent Form

Permission to consent for medical/optometric care to minor child or incapacitated adult.
  • Patient Information:

  • Date Format: MM slash DD slash YYYY
  • Please bring the patient's insurance card to the visit.
  • Authorized Person:

    A primary person and an alternate are recommended.
  • 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 Format: MM slash DD slash YYYY