Minor Consent Form

The state of Ohio requires consent before medical care can be given. In order for us to examine and/or treat a minor without his or her parent/legal guardian present, the parent/legal guardian should complete this form.

Name of Minor *

Birth Date of Minor *

I authorize Perimeter West Eye Care to provide eye care to my son/daughter, including, but not limited to, diagnostic examinations, measurement of ocular pressure, dilation of pupils, and if requested, contact lens fitting and evaluation, and necessary treatment for eye injury or disease as deemed appropriate by his/her optometrist.

This consent will remain in effect indefinitely until the patient reaches the age of eighteen, unless revoked in writing to Perimeter West Eye Care.

By signing below, I acknowledge that I have read and agree to this consent.

I am the parent/legal guardian of the minor listed above

Authorization – must be signed for insurance purposes

I authorize this office to release any information necessary to expedite insurance claims. I understand that I am responsible for all charges, regardless of insurance coverage.