Please list all medications you are currently taking (including eye drops):
We recommend yearly eye examinations. Contact lens prescriptions expire after one year; eyeglass prescriptions after two years.
Family History: Has anyone in your family (blood relative) had any of the following in the past?
CONSENT TO TREAT
By signing this form, I consent to treatment for myself and/or on the behalf of the Minor for which this information pertains. I give my permission for the doctor(s) to examine, diagnose, and initiate treatment as deemed appropriate. I further attest that I am the Parent/Legal Guardian of the Minor and have the authority to authorize care or treatment.
While the Eye Group, P.C. is happy to file my insurance for me, I understand I am responsible for all charges should my claim be denied.