Minor Consent Form

The patient has my permission as legal guardian to be seen and treated without being accompanied by myself or another adult (this visit and future visits). I understand that I will be responsible for the bill, should insurance not pay, even if I am not present at the time of the patient's visit.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Patient's Name

Date of Birth

Witness Signature

Date

Patient / Agent / Guardian Signature

Date

Your information will be encrypted.

Minor Consent Form

CLEAVER DERMATOLOGY