Under 18 Guarantor Form

Patients under the age of 18 require a guarantor on file. Please complete the following for our records.

Patient Name (as it appears on patient insurance card):

Patient Date of Birth:

Guarantor Information (Financially Responsible for Patient Balances for above Patient):

Parent/Guardian’s Name:

Parent/Guardian Date of Birth

Parent/Guardian’s Street Address:

Unit/Apt No.:

City/State

ZIP

Parent/Guardian’s Telephone:

Home

Work

Cell

Parent/Guardian’s Email Address:

Note: The above information will be used for patient billing. This is the address where patient statements will be sent, and the number our office or representatives will use for billing concerns.

I understand that I may remove these privilege or change the information on this form by notifying Georgia Skin Specialists in writing.

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.

Printed Name of Parent/Guardian:

Signature of Parent/Guardian:

Date

Your information will be encrypted.