CONTACT INFORMATION

REGISTRATION DETAILS

PARENTAL CONSENT TO TREATMENT

After a screening, if glasses alone cannot correct a problem, the child will receive a complete eye exam.  Some eye diseases may still not be found.

▪︎ The undersigned hereby consents to any medical treatment or hospital services rendered the patient under the general and special instructions of the attending physician and other assigned physicians or paraprofessionals providing care to the patient.

▪︎ I also acknowledge that no guarantee or warranty has been made by said physicians of Wills Eye Ophthalmology Clinic, Inc. (WEOC) as to the result of any treatment or procedure which may be given or performed. For the purposes of advancing medical education, I consent to the presence of observers to the patient’s treatment.

▪︎ Wills Eye Ophthalmology Clinic, Inc. is hereby authorized to release all or any part of the medical record including information concerning substance abuse, mental illness or HIV status of the patient named on this form for the purposes of treatment, payment, or operations.

PARENTAL CONSENT TO PHOTOS & RECORDINGS

I consent to having photographs and recordings of my image and voice, and I agree that upon creation, those images and recordings are owned by Wills Eye Hospital. I agree to release Wills Eye Hospital and its affiliates for the use of these images and recordings. I authorize the use of my medical information for teaching and research purposes.