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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
MM slash DD slash YYYY
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.

Signatures:

The signature and consent of ONE parent is sufficient.

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

MM slash DD slash YYYY
Name
Max. file size: 512 MB.