Myopia Control Consent Form

Myopia Control Program - Informed Patient Consent Form

Please carefully read over the following statements and check the boxes below each one.

I understand that the aim of the myopia control program is to slow how quickly my child’s myopia may worsen or progress over time.

I understand that my child’s myopia may continue to worsen even while undergoing myopia control management.

I have been advised on relevant intervention and treatment options available to my child, including possible considerations and complications of treatment, and consent to proceed with the myopia control program.

I have been advised on a recommended wearing/usage schedule (including the number of hours per day and days per week, if required) and understand the importance of adhering to this.

I have been informed about the considerations of not proceeding or complying with a myopia control intervention option and understand the possible implications of this.

I understand that from time to time my eye care professional may suggest a different myopia control intervention method based on the latest research.

I understand that my child must attend regular appointments to assess progress, which may be as frequent as every one, two, three, or six months as directed by my eye care professional.

I understand that there is an annual fee for the myopia control program which renews one year from the baseline assessment, even if I missed my child’s appointments within the paid year.

I understand that a comprehensive eye examination must be completed before enrolling in the myopia control program. If the examination was not done at Tonic Eye Care, I will provide the updated glasses prescription given within the past 1 year or get reassessed at Tonic Eye Care. I understand that a reassessment examination at Tonic Eye Care may not be covered by OHIP as it would be considered a second opinion.

Form Completed For:

Child/Patient Name

Date of Birth

Parent/Guardian Name

Date Completed