Consent for Minor Form

Phone: <a class="ecp-phone-call-phone" href="tel:618-744-7555" style="text-decoration:none"> 618-744-7555
Email: Helfrichfamilyeyecare@gmail.com (Do not send personal health information by email.)

This form must be completed if a minor will not be accompanied by a parent/guardian.

Child's name:(Required)

Child's date of birth:(Required)

I am the parent or guardian of the child listed above who is a minor child, and I authorize examination and treatment by staff and Doctors at Helfrich Family Eye Care. This includes any testing, diagnosis, and treatments as needed.(Required)

I have read and understand the above information and the information given to me. By my signature below, I consent to Helfrich Family Eye Care to examine and treat my child.(Required)

Parent/Guardian Name:(Required)

Parent/Guardian Signature(Required)

Date(Required)