Consent Forms and Documentation

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New Patients:

If this is an appointment for a new patient, consent forms must be signed at the appointment by a parent or legal guardian. We will ask to see a current insurance card and the parent's or legal guardian's driver's license at the time of the appointment.

 

Returning Patients:

If this is not your first appointment with our office, the consent forms may have expired. Documents scanned into your child's medical chart are valid for one (1) year. In order to prevent any interruptions in your child's care, we may ask that updated consent forms to be signed at the appointment by a parent or legal guardian. We will also ask to see a current insurance card. 
 
Please note: Each child is required to have their own set of signed consent forms and documents.
 
If the necessary consent forms cannot be signed by a parent or legal guardian at the time of the appointment, we will reschedule your child's appointment. This is important to keep in mind if a family member (other than a parent or legal guardian) or a friend will be bringing your child to the appointment.
 

Are you a foster parent? 

Please bring the “Responsible Party for Medical Expenses and Consent for Treatment” letter provided by the Idaho Department of Health & Welfare to the appointment. 
 

Online Consent to Treat Form: 

Please note: If you (the parent or legal guardian) are unable to accompany your child to his/her appointment with our office, please complete our convenient "Consent to Treat" form ahead of your child's appointment.
 
With your written permission we can see your child, providing seamless care with the convenience busy parents appreciate.

Please complete the "Consent to Treat" form below and click submit.
(A PDF of the form will be emailed to you for your signature) 


Please sign the form (electronic signatures will not be accepted), attach a copy of your driver's license, along with copies of insurance cards. 
This information may be:

  • Presented to our office at the time your child checks in for his/her appointment
  • Faxed to our office: 208.639.0329
  • Emailed to our office: info@artisanpediatriceyecare.com

Name*Contact EmailYour Relationship to Patient
I hereby voluntarily consent to the rendering of such care, including diagnostic procedures and treatment, by authorized members of the Artisan Pediatric Eyecare staff or their designees, as may in their professional judgment be necessary. I further understand that if my child is a minor and drives himself/herself to the appointment, his/her eyes will not be dilated unless an adult driver is present to drive him/her home from the appointment.
Childs Date of Birth
I hereby acknowledge that no guarantees have been made to me as to the effect of such examinations or treatment on my child?s condition. I have read this form and certify that I understand its contents. I hereby give our (my) consent to: Artisan Pediatric Eyecare who will be caring for our (my) child:
Childs First and Last Name:Period of care beginning
Period of care ending
I acknowledge that I am responsible for all charges in connection with care and treatment rendered during this period. I further agree to pay all charges at the time of check-in for each appointment.
Parent/Legal Guardian Name:AddressPhoneWork PhoneChild's Allergies, if any:Medicines child is takingFamily Physician/PediatricianEmergency ContactVision InsuranceName of SubscriberSubscriber IDMedical InsuranceName of SubscriberSubscriber ID

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