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CONSENT TO TREAT MINOR DEPENDENT

By signing this form, you are giving Commerce Family Eyecare and its doctors permission to examine and treat your minor/dependent child without your presence. Your signature below, as the parent or legal guardian, serves in place of any required signatures on the office's standard patient forms. This consent remains valid until revoked in writing.

Patient Name *

Parent/Guardian Name *

Relationship to Patient *

Signature (Type your full name) *

Date *

Day

Month

Year