Parental Permission Form

Parental Permission Form

To Whom It May Concern:

The University of Houston-College of Optometry will be at your school soon! The school nurse has sent home this form which, when signed by the parent or guardian, will allow the College of Optometry to examine your child’s eyes.

When you complete and sign this permission form, you give the University of Houston College of Optometry permission to dilate and examine your child’s eyes.

My child’s name is: ______

My name is: ______

Please check off any of the following eye conditions your child currently has or has had in the past.

Eye Disease ______Lazy Eye______Eye Injuries ______

Turned Eye ______Glaucoma ______Cataracts ______

Eye Surgery ______Vision Therapy ______Glasses ______

Double Vision ______Flashing Lights ______Laser Treatments ______

Color Vision Defects ______Using Any Eye Medications ______

Please tell us more details about any of the conditions you checked above: ______

______

______

______

______

______

Signature of Parent of Guardian Date

Address (Optional)

______

______

______

Page 2