Consent to Treat a Minor

Please correct the errors described below.

The following statement was read by the parent/guardian listed above:

I give written permission for Access Dermatology, P.C. and its representative physicians to make medical
decisions/treat my child as listed above, since I, the parent/legal guardian listed above may not be present at
all his/her scheduled visits.

I understand that I or another parent/guardian must be present for my child’s first appointment. I also
understand this signed consent will be valid until the minor child is 18 years of age, or unless I withdraw this
permission in writing.

I certifiy that I understand and agree to the foregoing permission statement.

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.

Your information will be encrypted.

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