If yes, please list which family member(s)?
When did you start smoking?
If yes, how much do you smoke? blanks
I, First Name Last Name (parent or legal guardian), give consent to Professional Family Eyecare to arrange, schedule, and/or provide health care services, including the administration of tropical anesthetic drops and a prescription for medicinal drugs, if needed, to First Name Last Name , as deemed necessary for the health and welfare of said minor child. This authorization is effective from the date of signature. Minor Child's NameFirst Name Last Name Signature of Parent or Legal GuardianSignature Relationship to ChildType a label Date