Consent to Treat Minors

the parent or legal guardian of

Date of Birth

Grant permission for my child to be treated at Dermatology Associates of Morris, P.A., Parsippany, New Jersey.

Treatment may include (please check):

General medical care

Minor surgery which may be accompanied by the administration of local anesthesia (Lidocaine).

Please list any allergies and/or medical conditions that we should be aware of:

Name of Person/s authorized to bring in minor

This authorization is effective (please check)

Today Only

From

At the time of the visit, the parent/guardian can be located at the following phone number

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.

Name

Phone Number

Signature of Parent or Legal Guardian

Your information will be encrypted.