SVS – Minor Consent Form – Patient Registration Forms

CONSENT FOR MEDICAL/OPTOMETRIC CARE TO A MINOR CHILD OR INCAPACITATED ADULT

The parent or legal guardian of the following minor child or incapacitated adult (“Patient”) hereby consents to optometric/medical care for the Patient to be performed by Optometrists and/or other personnel employed or contracted by SVS Vision, Inc. Such optometric/medical care may include, but is not limited to, comprehensive eye examinations, glaucoma testing, pupil dilation, contact lens fitting (including contact lens class and all subsequent follow-ups), vision therapy, and other diagnoses and/or treatment rendered to the Patient on the advice of the Patient’s Optometrist(s). This consent is effective whether or not the parent or guardian is present when the optometric/medical care is rendered.

Name of Patient

First Name Last Name

Date of Birth

Insurance Type:

Insurance Number:

Do you have a secondary vision insurance?

Yes

Insurance Type:

Insurance Number:

A separate consent form for each patient is required. This consent shall be effective for six (6) months from the date signed by the parent or guardian; however, this consent may be revoked at any time in writing by the parent or guardian.

The consent of ONE parent is sufficient.

Guardian: please attach a copy of Letters or Orders establishing Guardianship

Consent(Required)

Check to confirm that the details of this form are accurate and up to date

I Confirm

Name(Required)

Parent or Guardian First Name Parent or Guardian Last Name

Parent or Guardian Phone number

Date

File

Max. file size: 512 MB.