Eye/Vision Exam Form

Patient Information

Medical History

Has your child ever been diagnosed with, or experienced any of the following conditions? Check Y, N, or ?

  • Y N Unsure
  • Y N Unsure

Please check child or family to indicate medical history:

  • Child Family
  • Child Family

  • Does your child have glasses?

  • Do they wear them regularly?

  • How long have they had these glasses?

  • Are they Lost or Broken?

  • Do they receive routine Eye care?

  • What grade is your child in?

  • What is your child's teacher's name?

Insurance Information

Those with Insurance will receive a FULL exam.
Those without Insurance will receive a Screening.
Those that do not pass the Screening are provided a full exam.
Your insurance WILL be billed. You will NOT be billed for the balance. We participate wiuth all insurance companies.


I request and authorize Quality Care for Kids to perform an eye and vision test on my child. I authorize my Commercial, Medicaid or other Insurance Benefits, be paid directly to Quality Care for Kids. I authorize QCFK to provide a summary of findings to my child’s school, physician or specialist if a problem is identified. I’m also signing below to acknowledge that I have received QCFK’s privacy notice that was attached to the front of this consent.