Permission to exam/treat minor

Monday: 8:30 AM - 5:00 PM
Tuesday: 8:30 AM - 5:00 PM
Wednesday: Closed
Thursday: 9:00 AM - 7:00 PM
Friday: 8:30 AM - 5:00 PM
Saturday: 8:30 AM - 1:30 PM
Sunday: Closed

Name: TotalVision Eyecare of Glastonbury
Address: 63 Hebron Ave, Glastonbury, CT, 06033, US
Telephone: (860) 659-5900
Price range: $000 - $300

Name
First Last
Email
Name of the Child
First Last
*
I, give my permission for Dr. Lindower to examine and treat my dependent child, while I am not present, as indicated below. I agree to be responsible for all charges not covered by insurance.
Allow*
- Comprehensive eye examination
- Contact Lens fitting
- Administration of drops for dilated retinal exam
- Optomap Retina Scan (Retinal Photography - $39 fee)
- Examination, treatment & prescribing for red eye, eye problems and infections
This authorization is good for*
- Today Only
- All Visits for 1 year from date of signing note
Signature*
Hidden
Date
MM slash DD slash YYYY

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TotalVision Eyecare of Glastonbury