Consent to Treat Minors Form

* Patient Information

* Choose the office location for your appointment:

* Patient Name:

* Date of Birth:

Parent/Legal Guardian Information

* Name:

* Relationship to Patient:

* Legal Guardian Phone:

* Date of Birth:

Special Permissions: This agreement is required for the minor child to be seen and treated without the parent/legal guardian present.

(Initials) Unaccompanied: I grant permission to treat and provide any healthcare services to my child that the provider deems necessary for treatment if my child arrives at the office unaccompanied.

(Initials) Accompanied by Others: If I am unable to accompany my child to the appointment, the below listed individuals have my permission to accompany my child and make medical decisions regarding my child.

Other Individuals to Accompany Minor

Name of Authorized Individual:

Relationship to Patient

Date of Birth:

Name of Authorized Individual:

Relationship to Patient

Date of Birth:

Consent to Treat Minor: I authorize Dermatology Associates to treat and provide any healthcare services to my child deemed necessary for treatment and/or diagnosis. I also understand that, in the course of that treatment, photographs may be taken for clinical purposes. I acknowledge that this consent will remain in effect until I revoke it in writing and present this document to the office or the minor reaches the age of 18 years.

By signing below, I certify that I have read the above information and have had any questions answered. My signature also certifies my understanding and agreement with the above information.

* Signature of Authorized Representative:

* Date Signed: