a minor, do hereby voluntarily consent to allow members of Towne Lake Eye Associates staff to use their professional judgement to render care to my child as they determine necessary.
This care may include diagnostic procedures and appropriate medical interventions.
I further acknowledge that I am responsible for all reasonable charges in connection with the care and treatment provided. When applicable, I authorize Towne Lake Eye Associates
and the doctors providing treatment to release medical information, as necessary, to the designated insurance carrier to bill for payment.