Consent to Treat Minor
Please Fill Out if Patient is Under 18 Years of Age
Patient Full Name
Patient Date of Birth

I give my permission to Dr. Bruce Luong & Dr. Jessica Luong to treat my son/daughter without my presence. I understand that I am responsible for providing any necessary information regarding insurance coverage and I accept responsibility for any services and fees rendered that are not covered by my insurance.

Signature of patient / legal guardian (type your name)

Relationship to patient



1016 E. Hebron Pkwy Ste 150
Carrollton, TX 75010
(469) 480-6150
HOURS OF OPERATION    
Monday
9:30am - 6:00pm
Tuesday
9:30am - 6:00pm
Wednesday
9:30am - 6:00pm
Thursday
Closed
Friday
9:30am - 6:00pm
Saturday
Appt. Only
Sunday
Closed
Framed Eyecare 1016 E. Hebron Pkwy Ste 150 Carrollton, TX 75010 Phone: (469) 480-6150

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