Treatment to Minors

Patient Name:

Date of Birth:

Many times parents/guardians 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.

I hereby grant Dr.

permission to treat my child when they arrive at the 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.

Signature of Parent:

Date:

Your information will be encrypted.