TFCZ01 Minor Consent Form

MINOR CONSENT FORM

To be completed by the parent/guardian of a patient 17 years old or younger.

I certify that I am the parent and/or legal guardian of the below named patient, and I consent to the examination and treatment of the patient by The Foot Clinic Staff, LLC/Dr. Ali Davis, DPM.

Patient Name *

First Name

Middle Name

Last Name

Date of Birth *

Date

I authorize the person/s listed below to bring the patient to their appointments at the Foot Clinic, LLC.

	Name	Relationship to patient
1.
2.
3.
4.

Digital Signature Authorization: *

I certify that I am the person represented on this form or I have the legal authority to sign on their behalf. I also understand that the digital signature below is a valid legally binding signature.

Parent/Guardian Signature *

Name

First Name

Last Name

Date