Dermatology Center of N. Ms., P.A.

Many times parents find themselves unable to accompany their teen or young adult children to appointments. This form has been prepared for your convenience should you at some time be unable to accompany your child.

In the event your child needs high risk medication a parent must be present for the initial evaluation. Your signature will also be required on the high risk medication consent.

I hereby grant to Dr. Harber, Dr. Jeffrey C. Houin Jr., Dr Bradley N. Greenhaw, and their ancillary staff, permission to treat my child when they arrive this office unaccompanied.

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.

This consent automatically expires when my child reaches the age of 18. I understand that I may revoke this consent at any time. I also understand I must submit my revocation in writing.

Note: This document does not release the patient/parent from his/her financial responsibilities the date the services are rendered.