Permission to exam/treat minor 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*HiddenDate MM slash DD slash YYYY
