AFFZ11 Consent for Medical Treatment of a Minor Child

Consent for Medical Treatment of a Minor Child

***Parent or Legal Guardian MUST accompany minor on first visits***

Patient Name *

First Name

Middle Name

Last Name

Patient Date of Birth *

Date

Appointment Date *

Date

I authorize Affiliated Dermatologists and its clinicians to evaluate and treat my minor child for routine, non-urgent dermatology care related to established conditions (for example, acne) when I am not present, including follow-up visits and prescription management/refills, and related lab orders as clinically indicated. This authorization remains in effect until I revoke it in writing, or the child turns 18, whichever occurs first.
Services that materially increase risk or are elective cosmetic in nature will require
separate consent.

Parent or Legal Guardian’s Telephone Number *

Please enter a valid phone number.

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 or Legal Guardian’s Signature *

Name of Parent or Legal Guardian *

First Name

Last Name