 Eye Examination Consent Form.pdf
SAMPLE INFORMATION BELOW
*** Has your child seen an optometrist this calendar year? (January - December 2018)*** No Yes
Date of Eye Exam: STUDENT INFORMATION:Last Name:
First Name:
Name of School:
Date of Birth (MM/DD/YYYY):
Gender:
Grade:
Classroom #:
Manitoba Health Number (6 Digits):
PHIN Number (9 Digits):
Address – AS SHOWN ON MB HEALTH CARD (Street address, City, Postal Code):
STUDENT MEDICAL HISTORY:Eye Health History (Conditions, Injuries, Surgeries, etc.)
Is the student currently a patient of an eye specialist? No Yes
Medical Conditions, Current Medications, Allergies:
Family Medical History (Eye Conditions, Medical Conditions, i.e. Diabetes, Glaucoma, etc.): COVERAGE FOR PRESCRIPTION EYEGLASSES:In order to ensure the timely provision of prescription eyeglasses (if required), please provide the following information:
Treaty or Status Number (Non-Insured Health Benefits) (if applicable) (10 Digits):
Employment and Income Assistance Number (Social Allowances Health Services Card) (if applicable) (6 Digits):
Private Insurance Coverage (if applicable):
Insurance Company Name:
Contract/Policy Number:
ID Number/Group Number:
Insured Member Name (Parent/Guardian of Student):
First:
Last:
Insured Member’s Date of Birth (Parent/Guardian) (MM/DD/YYYY): PERMISSION TO SHARE FINDINGS:With other Health Care Providers, as deemed appropriate (Family Doctor/Pediatrician/Other) YES NO
With Winnipeg School Division Staff YES NO CONSENT:Please sign below to provide consent for your child to receive a comprehensive eye examination, including dilation if necessary, by a fully licensed and accredited “MOBILE VISION CARE CLINIC INC.” Doctor of Optometry, and be provided with prescription eyeglasses, if required. **
Date:
Parent/Guardian Name (Please Print):
Parent/Guardian Signature:
Relation to Student:
Student Name – (if over 18 years of age ONLY):
Student Signature – (if over 18 years of age ONLY): ** ALL OPTOMETRIC SERVICES HEREIN WILL BE PROVIDED BY A FULLY LICENSED AND ACCREDITED “MOBILE VISION CARE CLINIC INC.” DOCTOR OF OPTOMETRY.
** ALL PRESCRIPTION EYEGLASSES PROVIDED HEREIN WILL BE FIT AND DISPENSED UNDER THE GUIDANCE OF A FULLY LICENSED AND ACCREDITED “MOBILE VISION CARE CLINIC INC.” OPTICIAN.
** CONSENT COVERS AN ANNUAL EXAMINATION FOR YOUR CHILD WHILE A STUDENT IN THE WINNIPEG SCHOOL DIVISION. | 