Exam Forms

The state of Idaho 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 *

First Name

Last Name

Birth Date of Minor *

Full Name

Email

Phone Number

Field Name

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.

Privacy Notice

I acknowledge that I have received a copy of Eyeguys Optical's Financial Policy and Privacy Policy. (forms are linked at top of page)

Checkbox

I authorize Eyeguys Optical to provide eye care to my minor, including, but not limited to, diagnostic examinations, measurement of ocular pressure, optomap, and if requested, contact lens fitting and evaluation, and necessary treatment for eye injury or disease as deemed appropriate by his/her optometrist. An Eyeguys staff member will contact the parent/guardian after the exam for payment that is required at the time service, and to discuss glasses and contacts if deemed necessary. I understand that I am still financially responsible for all medical expenses incurred by my minor during these appointments.

Full Name *

SUBMIT

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Exam Forms

EXAMS

INSURANCE AUTHORIZATION

HIPAA

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