Treehouse Eyes co-management form Please click here to schedule a 15 minute zoom meeting to learn about co-management. PatientDate of Birth Date Format: MM slash DD slash YYYY GenderMFParent’s Name First Last Email PhoneParent’s preferred contact methodemailphoneThe patient’s parent has had their questions answered regarding the consequences of treating versus not treating their child’s myopia (for example, possible eye health implications of increasing myopia).YesNoEthnicityAsianBlackLatinoCaucasianPatient has been myopic for approximately (years)Parents myopicYesNoWho Mother Father Siblings myopicYesNoHow many myopic siblings VA sc: OD: 20/OS: 20/Current Subj Rx: OD:20/OS:20/Previous Rx: (date) Date Format: MM slash DD slash YYYY OD: 20/OS: 20/Estimated digital device useEstimated time outdoorsReferring DoctorDoctor’s email Will you be co-managingYesNo