Medical Authorization for Minors Form

Minor's Name

First Last

I am parent or legal guardian of the above minor

Parent

Guardian

I do hereby authorize in advance, Parkland Eye & Vision Clinic, PLLC as our agent, to provide any medical or surgical diagnosis or treatment and medical care which is deemed advisable by and rendered under the general or specific supervision of Dr. Paul A. Williams or Dr. Brian P. Finley in my absence.

It is understood this authorization is given in advance of any specific diagnosis, treatment or care being required but is given to provide authority and power on the part of the aforesaid agents to give specific consent to any and all such diagnosis, treatment, or care which Dr. Paul A. Williams or Dr. Brian P. Finley may deem advisable.

This authorization shall remain in effect unless revoked in writing by the undersigned.

Parent or Guardian Name

First Last

Parent or Guardian Signature

Date

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