Has your child ever been diagnosed with, or experienced any of the following conditions? Check Y, N, or ?
Please check child or family to indicate medical history:
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?
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.
* By typing your name into the signature field, this is considered the same as if you had signed this document