Coastal Family Eye Care

Consent to Treat Minor

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Consent to Treat Minor

To be completed by a parent or legal guardian. Fields marked * are required.

Minor's Information

Parent / Legal Guardian

Authorized Person (if different from guardian)

If someone other than the guardian may bring the minor to appointments, please list them here.

Consent

I, the undersigned parent or legal guardian, hereby give consent for Coastal Family Eye Care to examine and treat the above-named minor. I understand that I am responsible for all charges incurred.