• Welcome Back to Professional Family Eyecare

  • Current Eyewear and Contacts

  • Eye Health History

  • Primary Care Information

  • Medical History

  • Family Eye/Medical History

  • Consent To Provide Health Care Services To Minor Child

    Fill Out For Minors Only.
  • I,         (parent or legal guardian), give consent to Professional Family Eyecare to arrange, schedule, and/or provide health care services, including the administration of topical anesthetic drops and a prescription for medicinal drugs, if needed, to      , as deemed necessary for the health and welfare of said minor child. This authorization is effective from the date of signature.

    Minors Child's Name
          

    Child's Date of Birth
    Pick a Date   

    Signature of Parent or Legal Guardian
       

    Relationship to Child
       

  • Patient Financial Responsibility

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  • Should be Empty: