CONSENT TO TREAT MINOR CHILD

Consent(Required)

I do hereby consent to any eye care services
and the administration of anesthetic and dilation drops determined by a physician to be
necessary for the welfare of my child while said child is under the care of Curington Eye
Associates, PA D\B\A Family Vision Center of Brevard County, Florida

Name of Patient (minor)

First Last

Name of parent/legal guardian

First Last

DOB

This authorization is effective day of

Signature of Parent or Legal Guardian

Date

Witness Signature

Witness Name (please print)

First Last

Family Address:

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Father’s Telephone:

Mother’s Telephone:

Child's Physician:

First Last

Phone:

Insurance:

Policy #

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