Authorization to Treat a Minor Form - Towne Lake Eye Associates

Treating a Minor Authorization

If a child under age 18 presents without a parent or guardian, we require the following form to be signed by the parent or guardian.
Online Authorization to Treat a Minor Presenting without a Parent or Guardian

If a child under age 18 presents without a parent or guardian, we require the following form to be signed by the parent or guardian.

I, undersigned parent or legal guardian of (child's name)

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.

Relationship:

Parent or Guardian signature

(By entering your name here, you are digitally signing this form)

In case of emergency, I can be reached at the following phone number: