Affiliated Dermatologists of Virginia

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I, (Parent or Legal Guardian's Name), parent or legal guardian of (Patient Name), (Date of Birth) do hereby consent to any medical care determined by an Affiliated Dermatologists of Virginia (ADOV) provider to be medically necessary for my child while said child is under the care of (Person Accompanying Minor), relationship to child (State below.)

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I understand that this authorization is given in advance of any specific diagnosis or treatment, however authority is given to the above named adult to give consent to any and all diagnosis and treatments as recommended by the physician.

I understand that I remain financially responsible for any expense incurred by the minor patient.

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

If Applicable:

In the event that my child is of driving age and I will not be accompanying him/her to their doctor appointment I authorize treatment as deemed medically necessary by any ADOV provider and assume all financial obligations for said treatment.

Office policy requires any minor not accompanied by their parent or legal guardian have signed consent for care. Any minor without consent will need to reschedule their appointment.

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