Serve the People A Non-Profit Organization

Medical Disclosure
Section 2: Consent for Eye Exam & Insurance Benefits

By consenting to this form, your child will receive an eye exam by an optometrist through Serve the People Community Health Center, and glasses will be provided by Medi-Cal or donated by Serve the People during one of our scheduled clinics.

By consenting to this form, I understand that:
- I give my permission for my child to participate in the Mobile Vision Clinics program through Serve the People. If my child has eligible Medi-Cal benefits, including replacement benefits, I give my permission to Serve the People to use those benefits for the exam and/or glasses. If my child does not have insurance or eligible benefits it will not affect their ability to receive an eye exam or glasses through Serve the People.
- I understand the optometrist may recommend my child receive a dilated eye exam. Dilation eye drops are safe and routinely used on children to help provide a more accurate prescription and health evaluation when necessary. Dilation can cause your child to experience temporary blurry vision and light sensitivity, but sunglasses will be provided for your child's comfort if the drops are used. I may choose to decline the dilation, which will not affect my child's eligibility to receive
- I give Serve the People permission to share my child's vision exam results with Anaheim Union High School District (AUHSD) for the purpose of giving prescription glasses. The information shared includes if my child was prescribed glasses, and if follow-up care is needed. I understand that the information will be part of my child's school record. If choose NOT to share my child's eye exam results with AUHSD it will not affect my child's eligibility to receive an eye exam or glasses through Serve the People.
- I understand that Serve the People's "Notice of Privacy Practices" provides information about how it may use and disclose patient health information. I, the undersigned parent and/or legal guardian of the minor age child, acknowledge that have the right to review Serve the People Community Health Center's "Notice of Privacy Practices" prior to signing this consent. Serve the People Community Health Center has a fixed location at 1206 East 17th St, Santa Ana, CA 92701.
- I agree to hold AUSHD, its officers, employees, and agents harmless from any and all liability and claims arising out of or in connection with my child's participation in this activity as provided for in California Education Code Section 35330. This waiver, however, shall not apply to any injuries or damages that arise solely out of the negligence of employees or agents of the District.

CONSENT
I give my consent for my child to have the following services without me present:

Please circle Yes or No for each item.
Permission to examine my child's vision. A comprehensive eye exam includes evaluations of how the eyes work together, whether a child needs glasses or not, and to determine if a child's eyes are healthy.

YesNo
Permission to use dilation drops. Dilation eye drops help the doctor provide a more thorough eye exam when necessary. By declining, you do NOT give us permission to use drops even if the doctor recommends it.

YesNo
Permission for Serve the People to share my child's vision exam results with the Anaheim Unified School District for the purpose of giving prescription glasses and to facilitate with any follow up care as recommended by the doctor.

YesNo
Parent/Legal Guardian Signature (MUST sign)*

Clear
Date

MonthDayYear
Date
Parent/Legal Guardian Printed Name*
Relationship to Child*
Should be Empty:

Mobile Vision Clinic Consent